Minimal Dissection Research Articles

Soft Tissue Structures at Risk With a Percutaneous Focal Dome Osteotomy: A Cadaver Study

The focal dome osteotomy allows deformity correction through frontal plane rotation, and if needed, anterior or posterior translation. This percutaneous technique allows extracapsular ankle realignment with minimal soft tissue dissection. While circumventing a standard anterior incision, this technique encounters soft tissue structures that must be considered. Focal dome osteotomies were simulated on 10 fresh-frozen below the knee cadavers. Centered proximal to the tibial plafond at the physeal scar, a radial arm using a 4-hole Rancho cube was used to map the dome. Medial, lateral, and central incisions were made to allow access for drilling and measured to nearby anatomic structures. Among 10 cadavers, the age and weight were 70 ± 7.96 years and 134.7 ± 30.8 pounds, respectively. In all cadavers, the hole below the most proximal posthole provided the ideal position for the creation of the osteotomy. The medial and central incisions were closest to the tibialis anterior tendon measuring 3.37 ± 2.48 mm and 0.43 ± 0.9 mm, respectively. The lateral incision and half-pin used to create the distal axis of rotation were closest to the extensor hallucis longus tendon, measuring 1.97 ± 1.92 mm and 1.27 ± 1.5 mm, respectively. Drilling the second hole from the top on a 4-hole Rancho cube, forming a 2.50 cm radial arm, created the ideal osteotomy arc. Though neurovascular structures were further away from respective incision and half-pin sites compared to tendons, in several specimens, anatomic variations held them closer, warranting preoperative handheld Doppler and mapping. Care should be taken to protect anterior ankle anatomy during dissection, drilling, and completing the osteotomy.

Functional outcome of intramedullary nailing of the femoral shaft fracture

Background & Objective: A common fracture is a femoral shaft fracture. The advantages of intramedullary interlocking nails make them the method of choice for treating femoral shaft fractures. These benefits include a small incision, minimal dissection, decreased rates of infection, nonunion, and malunion, shorter hospital stays and rehabilitation periods, excellent union, rotational stability and length maintenance, rapid recovery, and early weight-bearing. Therefore, the aim of this study was to analyze the functional findings from femoral shaft fracture intramedullary nailing. Material and Methods: This was a hospital- based, longitudinal, observational study. All patients with femoral shaft fractures admitted at UCMS-TH, Bhairahawa from the Emergency Department managed surgically from October 2019 to March 2020 were included in the study. Femoral shaft fractures with age ≥ 16 years were included while open fractures (Gustalio and Anderson type 2 and 3), pathological fractures,congenital anomaly of the affected limb, previous fracture of the affected limb were excluded. All the patients were managed surgically and followed for at least 6 months. The outcome was measured by the Thoresen scoring system at the end of 6 months. Results: In this study of 30 cases, the mean age was 30.47 years, male and female ratio of 2:1, the left side was affected in 18 cases, RTA was the most common mode of injury. Most of the cases were Winquist and Hansen type 2 and AO type 32B. In the majority of the cases, 27 cases (90%) had no complication while superficial infection in 2 cases and shortening was seen in 1 case. We found excellent results in 86.7% cases, good in 10% cases and fair in 3.3% cases. Conclusion: The excellent functional outcome in terms of alignment and range of motion obtained in this study in the majority of patients makes this technique more reliable. The method of choice for femoral shaft fracture in adults was due to its low complication rate, high incidence of union, shorter hospital stay and early mobility.

Intraoperative findings in children with transthoracic wrap migration

IntroductionA frequent complication of Nissen fundoplication procedure is the migration of the wrap towards the thorax. The minimal paraesophageal dissection proposed by St. Peter has led to a significant decrease in this complication. This paper aims to report the intraoperative findings in children who presented with transthoracic wrap migration to try to establish the mechanisms that cause this condition. MethodsAn IRB exempt review of children with transthoracic wrap migration. Demographic factors, radiological findings, endoscopic and intraoperative findings were analyzed. Descriptive statistics were employed as measures of relative and central frequency. ResultsIn 10 years, 47 patients were treated. The migration of the wrap occurred at 37.61 months on average. In 95.21% of children, the migration occurred in the anterior part of the hiatus. This was also associated with a short esophagus in 8.5% of patients. DiscussionWe found that in over 90% of patients the migration occurred in the anterior part of the hiatus, which corresponds to the phrenoesophageal ligament. This reinforces the importance of keeping the ligament intact through minimal dissection, or if dissection is absolutely necessary, the phrenoesophageal ligament should be reconstructed. Level of evidenceII-B

Day microsurgery: Further application of free flap transfer as an ambulatory surgery

Free flap transfer (FFT) is essential in soft tissue reconstruction and can be done under local anesthesia. However, there is no study evaluating the feasibility of FFT without hospitalization. This study evaluated the feasibility of day microsurgery-FFT as a day surgery without hospitalization. Patients who underwent day microsurgery were included. The FFT was performed under local infiltration and/or block anesthesia without sedation by a surgeon with enough experience in supermicrosurgery. We focused on minimal dissection and secure hemostasis to prevent possible complications. Patient characteristics, operative findings, and postoperative course were evaluated. Seventeen patients with a mean age of 40.4 years were included. All defects were of the upper extremity and due to trauma. Utilized anesthesia included local infiltration in 11 sites, digital block in 10 sites, wrist block in 12 sites, and elbow block in 4 sites. Used flap included superficial circumflex iliac artery perforator flap in 8 (47.1%) cases and short-pedicle partial toe flaps in 9 (52.9%) cases. The mean diameters of the anastomosed artery/vein were 0.88/1.29mm, and the mean operation time was 68.9min. All transferred flaps survived without total or partial necrosis. The postoperative course was uneventful except for 1 (5.9%) case with minor wound dehiscence. FFT could safely be performed without hospitalization in selected cases of an upper extremity defect. Supermicrosurgery and careful patient selection play an important role in safe day microsurgery.

Posterior surgical approach for excision of retrorectal epidermal inclusion cyst, a road less travelled by surgeon: case report

Retrorectal epidermal inclusion cysts are rare congenital cystic lesions, mostly an incidental finding usually diagnosed in middle-aged women. Surgical resection is the main stay of treatment and 3 operative approaches are commonly used: abdominal, trans-sacral/coccygeal (posterior), and combined abdomino-posterior depending on the nature and location of the lesion. We report a case of a 22-year-old male presented with complaints of on-off constipation since 4 years, perineal heaviness since 2 years. Based on digital rectal exam, trans-rectal ultrasound, computed tomography, and magnetic resonance imaging findings, a presumptive diagnosis of retrorectal cyst was made. Patient underwent excision of cystic lesion by posterior trans-coccygeal approach. Post operative histopathology confirmed diagnosis of the retrorectal epidermal inclusion cyst. On follow-up after one month, symptoms of constipation and perineal heaviness completely resolved. Posterior resection allows proximal extension for elimination of the infection and in cases of adherence of the cyst to surrounding structures or in malignancy, which require en bloc resection. Posterior approach for resection is preferred for patients with posterior retrorectal cyst or presacral cyst because it provides adequate exposure with minimum dissection.

Risk of Lymphedema and Death after Lymph Node Dissection with Neoadjuvant and Adjuvant Treatments in Patients with Breast Cancer: An Eight-Year Nationwide Cohort Study.

Knowledge on the impact of neoadjuvant and adjuvant treatments on post-surgery lymphedema (LE) in patients with breast cancer is limited due to methodological limitations and an insufficient sample size. We investigated the risk of LE in patients going through long-term anticancer treatment regimens using a national cohort from the Korean National Health Insurance Service database from 2011-2013. Incidence rate ratio, Kaplan-Meier analysis, and Cox proportional regression analysis were performed. A total of 39,791 patients were included. While minimal lymph node dissection (SLNB) reduced the risk of LE (hazard ratio [HR] 0.51) as expected, neoadjuvant chemotherapy (NAC) followed by SLNB did not reduce the risk. Adjusting for adjuvant chemotherapy (AC) as time-varying exposure decreased the risk of LE in the SLNB group (HR 0.51), but not the mortality risk (HR 0.861). A longer duration of NAC, especially taxane-based, combined with SLNB reversed the effect and increased risk of LE. The findings highlight the importance of not only early surveillance before and after surgery, but also long-term surveillance during adjuvant treatment by surgeons and oncologists in order to reduce the risk of LE.

Surgeon-Powered Robotics in Minimally Invasive Surgery: Case Report from Nepal

Minimally-invasive surgery is the standard of care in many surgical diseases. Robotic surgery has mitigated nearly all limitations of laparoscopic surgery but with a big cost tag. Surgeon-powered robotic instruments were developed with the concept of providing similar advantages to the robotic platforms but with affordable costs. We report three cases of hernia, one hiatus hernia, and two inguinal hernias managed using surgeon-powered robotics platform. It provides additional maneuverability in minimal invasive surgical dissection and suturing. Surgeon powered robotic surgery may be a cost-effective viable alternative to robotic surgery in developing country like Nepal.

Posterior Cranial Distraction in Craniosynostosis: A Systematic Review of the Literature.

Posterior cranial distraction (PCD) is a surgical technique to address craniosynostosis, especially in syndromic patients. The technique has the ability to significantly expand the cranium, while requiring minimal dural dissection, compared to cranial remodeling. Our goals were to determine the patient characteristics and surgical outcomes of PCD. The two questions that we sought to answer were: 1) What is the average published complication rate and the most common complications of PCD? and 2) How much intracranial volume expansion can one expect with PCD? A PubMed database search of articles on PCD was performed. Case reports and articles with overlapping patients were excluded. A systematic review was performed using the remaining articles. Patient data were extracted in order to determine the total number of patients, patients with a syndrome, types of syndromes, mean age at surgery, mean distraction distance, mean increase in intracranial volume, and complications. 18 articles representing 325 patients were analyzed. A syndrome was present in 68.6% of patients. The mean age at time of surgery was 22.1 months. Mean distraction amount was 24.7 mm. Mean increase in intracranial volume was 253.2 cm3. The overall complication rate was 32.2%, with the most common complications being surgical-site infection, hardware-related complications and delayed wound healing. PCD is a powerful technique in the management of syndromic craniosynostosis, although complication rates are significantly higher than traditional remodeling techniques. Future studies should compare the effects of supratorcular and infratorcular osteotomies on intracranial volume, cosmesis and complications.

The Novel Use of Rare Earth Magnets for the Extraction of Metallic Soft Tissue Foreign Bodies in Children.

Metallic foreign bodies (mFB) are common following penetrating injuries in children. The mFB commonly occur in the head and neck region and extremity soft tissues. Removal may be indicated due to morbidity related to pain or migration. Extraction can be challenging to localize, often requiring wide exposure, and may be difficult to achieve in cosmetically sensitive areas. Different technological adjuncts have been used to facilitate foreign body removal including fluoroscopy, ultrasound, and more recently in adults, surgical magnets. The most powerful commercially available magnets are rare earth magnets comprised of neodymium iron and boron (Ndy). With the goal of reducing radiation exposure and the morbidity of mFB removal with associated soft tissue injury in children, a strategy was introduced utilizing Ndy to optimize extraction with minimal soft tissue surgical dissection. Two children with extremity mFB treated with Ndy between January 2021 and July 2021 were analyzed. We utilized commercially available ring type neodymium-iron-boron magnets with dimensions of 1 3/8-inch outer diameter x 1/8-inch inner diameter and 1/16 inch thick with a power of 13200 gauss that were processed for use according to our hospital protocols. Our main clinical indication was for the detection and retrieval of small ferromagnetic foreign bodies embedded in superficial extremity soft tissues. In the operating room under general anesthesia, the mFB were localized utilizing fluoroscopy. A 1.0cm skin incision was made into the subdermal soft tissues overlying the area of the mFB. No surgical tissue dissection was performed. The mFB could not be visualized in the soft tissue. Using fluoroscopy to localize the mFB, the Ndy was then placed into the wound in close proximity to the mFB. The mFB were immediately magnetized to the Ndy and the mFB were extracted from the soft tissues without any further surgical dissection. Two simple interrupted nylon sutures were placed to close the incision. The total operative time was 2 and 2.5minutes respectively. The children recovered uneventfully and are without complication. The use of Ndy to remove extremity soft tissue mFB in children appears to be feasible, safe, and efficient. Use of the Ndy allowed extraction via a small incision, optimizing the aesthetic result and avoiding the need for cross-sectional imaging, extensive surgical dissection, tissue reconstruction and prolonged operative time or x-ray exposure. The development of magnets of increasing energy density may be indicated to further optimize metallic soft tissue foreign body extraction in children in a minimally invasive manner.

An Easy Way to Harvest a Superthin SCIP Flap with Long Pedicle: Reappraisal of the Inferolateral Branches of the SCIA.

Despite being the first free flap used in reconstructive surgery, the groin flap slowly fell out of fashion because of its short pedicle length, small vessel diameter, variable vascular anatomy, and bulkiness. Over the years, the authors have found that perforators consistently exist inferolateral to the deep branch of the superficial circumflex iliac artery (SCIA), forming an F configuration with the main branch. The authors propose a new type of superficial circumflex iliac artery perforator (SCIP) flap design based on the perforators derived from these inferolateral branches of the SCIA. These perforators have the advantage of anatomic consistency and can be easily found by making an exploratory incision 2 cm caudal to the inguinal ligament. The perforators of the inferolateral branches extend directly into the dermal plexus, and thus can yield superthin flaps without microdissection defatting. Retrograde dissection allows the surgeon to elongate the pedicle to include a section or full length of the SCIA as needed and involving minimal muscle dissection. SCIP flaps harvested based on the perforators of the inferolateral branches of the SCIA were used successfully for six head and neck reconstructions and two trunk reconstructions with no major complications, including flap loss or lymphedema. The best indications for SCIP flaps based on the inferolateral branches of the SCIA are superficial soft-tissue defects that do not require much volume replacement.

Functional and Aesthetic Outcomes of No-Dissection Nasal Dorsum Using Subdorsal Septal Excision in Preservation Rhinoplasty.

Dorsal preservation (DP) caused privilege change in the concept of rhinoplasty and a promising superior functional and aesthetic transformation in rhinoplasty surgery. Avoiding dissection of the dorsal nasal bone and cartilage will leave the soft-tissue envelope intact, leading to a fine and smooth appearance, faster operation with less subsequent edema, and overall preservation of the dorsal aesthetic line. This prospective study included 113 patients who underwent DP rhinoplasty for nasal hump treatment with minimum dissection of nasal dorsum soft-tissue envelope. Results were evaluated using the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). The mean preoperative SCHNOS score was 7.21; the mean obstructive score was 2.95 ± 1.068 and the mean aesthetic score was 4.27 ± 0.771. The average lowering of the dorsal hump was 4.4 mm. Approximately 96% of patients showed improvement in the SCHNOS score after surgery, 86.7% (98 patients) showed improvement in the obstructive symptoms and 95.6% (108 patients) showed improvement in the aesthetic score. Complications were seen in 22.11% (most commonly residual hump in 13.27% of cases and dorsal indentation in 5.31%), bleeding was seen in 2.65%, and granuloma formation at the dorsal osteotomy site was seen in 0.88%. There was a very significant improvement in the aesthetic, obstructive, and overall SCHNOS score ( P = 0.000) for each parameter. DP rhinoplasty is a safe and very effective procedure, with very low risk of complications. Most of the treated patients have improvement of the obstructive and aesthetic outcome after surgery. Therapeutic, IV.

A comparative analysis of open vs minimal invasive lymph node dissection for testicular cancer using National Cancer Database

A comparative analysis of open vs minimal invasive lymph node dissection for testicular cancer using National Cancer Database

A Prospective Comparative Study of 3-Stitch Mesh Hernioplasty with Conventional Lichtenstein Repair.

Hernioplasty, in which a mesh is used to strengthen a weakness or defect in the inguinal wall, has replaced simple tissue repair. As it is associated with low recurrence, it is considered the gold standard and is one of the most common general surgical procedures. The ideal repair should be rapid, safe and simple to do, requires minimal dissection to create sufficient space, be cost-effective and be accompanied by a brief hospital stay, reduced pain, and fewer recurrences. The aim of the present study was to compare the efficacy of 3-stitch mesh fixation with that of traditional Lichtenstein mesh fixation of inguinal hernia repair. Between July 2018 and December 2019, 59 cases of primary, uncomplicated inguinal hernias were surgically treated. Both the classical Lichtenstein technique (group A, n = 30) and the Lichtenstein technique with the three-stitch fixation method (group B, n = 29) were used on patients with inguinal hernias. Between the two groups, the mean operative times, post-surgical pain scores, average hospital stays and postoperative complications including recurrence rates were compared. With a P-value of 0.001, the 3-point fixation group (group B) took 3.41 ± 0.58 min less time to fix the mesh than the Lichtenstein group (group A, 5.52 ± 0.59 min). The pain after surgery was much less for participants who had 3-point mesh fixation than for those who had conventional mesh fixation in the early (1, 3, 7 and 15 days after surgery) and late (1 month and 3 months) postoperative periods, with a P-value of 0.0001. When compared to the classical mesh fixation group, the 3-point mesh fixation group had less urinary retention, seroma and swelling. Both groups had the same number of other complications. The three-point hernioplasty is a simple procedure that is easier to adopt, less time-consuming, causes less trauma and has a lower risk of postoperative discomfort including chronic groin pain.

Prospective study of radiological and functional outcomes of humeral mid-shaft fractures by anterior bridge plating technique

Background: The humerus can be considered the most versatile bone in the human body. Can be successfully approached by a variety of methods for fracture fixation including functional bracing, plating (posterior, lateral, and anterior), and intramedullary nailing (antegrade and retrograde). Notably, many humeral fractures can be successfully managed conservatively due to the wide range of acceptability for reduction. Anterior bridge plating (ABP) which utilizes the minimally invasive approach popularly known as the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique can be said to be the latest entrant in this list. The present study was undertaken to evaluate the efficacy of ABP. Methods: The study was carried out from July 2020 to July 2022 in DR. D. Y. Patil medical college and hospital, Nerul, Navi Mumbai, involving 32 patients who met the selection criteria and were operated at the tertiary care centre. Informed consent was obtained from all the patients for use of their clinical and imaging data. Ethical committee approval was taken. The assessment of the patients was done based on functional and radiological outcomes periodically. Results: Majority of patients belongs to age group 18-25 years (46.87%). Majority of side of injury were found right side (65.62%). In most of the cases, the extent of the displacement of fractures were 2-5 cm (71.87). Conclusions: In conclusion ABP is a very good technique in treating mid-shaft humeral fractures with minimal soft tissue dissection, smaller scars, and early return to overhead activities.

Is systematic formal crural repair mandatory at the time of magnetic sphincter augmentation implantation?

Laparoscopic placement of the LINX Magnetic Sphincter Augmentation (MSA) device has become an accepted alternative to fundoplication in appropriate patients. Initial studies of MSA targeted to patients with 'early' disease allowed for the most minimal dissection of the esophagus to place the device, without hiatal dissection or repair (NoHHR), in patients with no or minimal hernia findings at surgery. Subsequent studies have compared systematic formal hiatal dissection and repair (Formal HHR) with the original minimal dissection technique. Review of published literature on MSA includes discussion on treatment of hiatal hernia at the time of implantation, accompanying the review of the physiology of the crural diaphragm. Formal hiatal hernia repair at the time of MSA implantation results in better control of reflux with less dysphagia and risk of postoperative hernia than NoHHR, regardless of the presence or size of hiatal hernia. Systematic crural repair should accompany any MSA implantation regardless of the presence or size of hiatal hernia.

"Cave-in" decompression under unilateral biportal endoscopy in a patient with upper thoracic ossification of posterior longitudinal ligament: Case report.

Thoracic ossification of the posterior longitudinal ligament (TOPLL) requires surgery for spinal cord decompression. Traditional open surgery is extremely invasive and has various complications. Unilateral biportal endoscopy (UBE) is a newly developed technique for spine surgery, especially in the lumbar region, but rare in the thoracic spine. In this study, we first used a different percutaneous UBE "cave-in" decompression technique for the treatment of beak-type TOPLL. A 31-year-old female with distinct zonesthesia and numbness below the T3 dermatome caused by beak-type TOPLL (T2-T3) underwent a two-step UBE decompression procedure. In the first step, the ipsilateral lamina, left facet joint, partial transverse process, and pedicles of T2 and T3 were removed. In the second step, a cave was created by removing the posterior third of the vertebral body (T2-T3). The eggshell-like TOPLL was excised by forceps, and the dural sac was decompressed. All procedures are performed under endoscopic guidance. A drainage tube was inserted, and the incisions were closed after compliance with the decompression scope via a C-arm. The patient's preoperative and postoperative radiological and clinical results were evaluated. Postoperative CT and MR films conformed complete decompression of the spinal cord. The patient's lower extremity muscle strength was greatly improved, and no complications occurred. The mJOA score improved from 5 to 7, with a recovery rate of 33.3%. UBE spinal decompression for TOPLL showed favorable clinical and radiological results and offers the advantages of minimal soft tissue dissection, shorter hospital stays, and a faster return to daily life activities.

Discussion

Discussion

Fundoplication in laparoscopic Heller's cardiomyotomy for achalasia.

Laparoscopic Heller's cardiomyotomy (LHC) is the preferred treatment of achalasia. It improves dysphagia by dividing muscles of the lower oesophageal sphincter, but this intervention can result in debilitating gastro-oesophageal reflux symptoms in some patients. To prevent these reflux symptoms, most surgeons add a fundoplication to Heller's cardiomyotomy, but there is no consensus regarding this or the type of fundoplication which is best suited for the purpose. To assess how the addition of a fundoplication affects postoperative reflux and dysphagia in people undergoing LHC and compare the different types of fundoplications used in combination with LHC to determine which is better at controlling reflux without worsening the dysphagia. We searched three databases (CENTRAL, MEDLINE and Embase) on 31 October 2021 and trial registers to identify all published and unpublished randomised controlled trials (RCTs) in any language, comparing different fundoplications used in combination with LHC to treat achalasia. We also included RCTs where LHC with a fundoplication is compared with LHC without any fundoplication. We only included RCTs which recruited adult participants with achalasia undergoing LHC with minimal hiatal dissection. We excluded non-randomised studies or studies involving paediatric participants. We also excluded studies where the procedure was done by open surgery and where circumferential hiatal dissection of the oesophagus was carried out, unless it was necessary to reduce a hiatus hernia or to facilitate a Toupet or Nissen fundoplication. Two review authors independently identified studies to be included, assessed risk of bias using the Cochrane RoB 1 tool, and extracted the data. We calculated the risk ratio (RR) with 95% confidence interval (CI) using both fixed-effect and random-effect models with Review Manager (RevMan) software. We included eight studies in this review, with a total of 571 participants with an average age of 45 years (range 33.5 to 50). LHC without any fundoplication was performed in 65 (11.3%) participants, 298 (52.1%) had Dor fundoplication, 81 (14.1%) had Toupet fundoplication, 72 (12.6%) had Nissen's fundoplication, and 55 (9.6%) participants had angle of His accentuation. Three studies with a total of 143 participants compared LHC + Dor to LHC without fundoplication. We found that the evidence is very uncertain as to whether the addition of a Dor fundoplication made any difference to the outcome of postoperative pathological acid reflux (RR 0.37, 95% CI 0.07 to 1.89; I2 = 56%; 2 studies, 97 participants; very low-certainty evidence) and uncertain for severe postoperative dysphagia (RR 3.00, 95% CI 0.34 to 26.33; I2 = 0%; 3 studies, 142 participants; low-certainty evidence). Three studies with 174 participants compared LHC + Dor to LHC + Toupet. The evidence suggests that there may be little to no difference in the outcomes of postoperative pathological acid reflux (RR 0.75, 95% CI 0.23 to 2.43; I2 = 60%; 3 studies, 105 participants; low-certainty evidence) and severe postoperative dysphagia (RR 0.78, 95% CI 0.19 to 3.15; I2 = 0%; 3 studies, 123 participants; low-certainty evidence) between the two interventions, but the certainty of the evidence is low. One study with 138 participants compared LHC + Dor to LHC + Nissen. Nissen fundoplication caused increased severe postoperative dysphagia (RR 0.19, 95% CI 0.04 to 0.83; 1 study, 138 participants; high-certainty evidence) when compared to Dor fundoplication. This study did not show a difference in postoperative pathological acid reflux (RR 4.72, 95% CI 0.23 to 96.59; 1 study, 138 participants; low-certainty evidence), but the certainty of evidence is low. One study with 110 participants compared LHC + Dor with LCH + angle of His accentuation, and reported that severe postoperative dysphagia was similar between the two interventions (RR 1.56, 95% CI 0.27 to 8.95; 1 study, 110 participants; moderate-certainty evidence), with moderate certainty of evidence. This study did not report on postoperative pathological acid reflux. When LHC was performed with minimal hiatal dissection, we were very uncertain whether the addition of a Dor fundoplication made a difference in controlling postoperative reflux, and we were uncertain if it increased the risk of severe postoperative dysphagia. There may be little to no difference in the outcomes of postoperative pathological acid reflux or severe dysphagia between Dor and Toupet fundoplications when used in combination with LHC, but the certainty of the evidence is low. Nissen (total) fundoplication used in combination with LHC for achalasia increased the risk of severe postoperative dysphagia. The angle of His accentuation and Dor fundoplication had a similar effect on severe postoperative dysphagia when combined with LHC, but their effect on postoperative pathological acid reflux was not reported.

Successful Reconstruction of a Defect Secondary to an Intersphincteric Abscess with Fournier’s Gangrene Using a Perforator-based Island Flap: A Case Report

Fournier’s gangrene, a soft tissue infection which is aggressive and sometimes lethal, often passes through deep fascial planes of the penis, scrotum, perineum, and lower abdomen; however, it rarely extends upward into the high intermuscular plane. We managed a rare case of Fournier’s gangrene with a high intersphincteric abscess from a perianal infection that resulted in a large defect in the anus and inferior aspect of the scrotum. A perforator-based island flap for the post-debridement defect was performed successfully. The perforator was selected near the defect along the lateral sacral border; the border of the flap design was adjacent to the defect, thus providing a sufficient angle of rotation near the pedicle with minimal dissection. Remnant undissected tissues around the pedicle prevented postoperative vascular complications. Additionally, the distal part of the flap design was elongated to the gluteal sulcus to be harvested as a very thin flap. This study suggests a perforator-based island flap as a secure and convenient option for covering a large defect involving the perianal region and inferior aspect of the scrotum.

Minimally invasive peritoneal access: A new approach of catheter placement for peritoneal dialysis.

Catheter implantation techniques for peritoneal dialysis (PD) have advanced significantly in recent years. We aimed to analyze the survival and associated complications of catheters inserted using a new technique that is guided by ultrasound and fluoroscopy and requires minimal tissue dissection. The procedure was performed by nephrologists in the outpatient basis, we compared these results of the minimally invasive insertion with traditional implantation using trocars. A total of 152 PD catheters were placed in 152 patients with stage 5 chronic kidney disease; 62.5% of the patients were men, with a mean age of 56.6 ± 18.5 years. The following two methods were used: minimally invasive insertion (MI group, n = 73) and trocar insertion (T group, n = 79). Patients in both the groups were followed prospectively for 26 months from the date of the first implantation. Gender, age, and prevalence of diabetes mellitus were not significantly different between the groups, while the body mass index, presence of obesity, and abdominal scars from previous surgeries were higher in the MI group (p = 0.021). The incidence of catheter dysfunction was lower in the MI group compared to group T (6.8% vs 20.3%; p = 0.019). Exit site infection was also lower with the new technique (4.1% vs. 18.9%; p = 0.005). Further, the cumulative incidence of peritonitis also reduced with MI (p = 0.034). Finally, the overall catheter survival at 1 year was 89%, which has been shown as higher in group MI (95% vs 82% in group T; p = 0.025). The MI technique for catheter insertion showed low complication rates and excellent catheter survival as compared to traditional implantation methods; thus, it may be an alternative method for PD catheter placement.