Minimally Invasive Procedure Research Articles

Pilot Study and Preliminary Results of Biodegradable Intramedullary Nailing of Forearm Fractures in Children

(1) Background: Diaphyseal forearm fractures are a common injury in children and adolescents. When operative treatment is needed, elastic stable intramedullary nailing (ESIN) is the most common surgical procedure. Although there is no clear evidence, hardware removal after fracture healing is performed in many patients. Often, the primary minimal invasive incision needs to be widened during implant removal. In order to decrease the burden of care of pediatric fractures, significant efforts were made to develop biodegradable implants, which make hardware removal unnecessary. Our study will conduct an observational trial on the clinical use of the Activa IM-Nail™ in forearm fractures in children between 3 and 13 years of age. The objective of this trial is to evaluate the risks and benefits of the Activa IM-Nail™. Among other objectives, the rate of refracture will be determined. (2) Methods: An international Europe-based, multicenter, prospective, single-arm, open-label study will be performed to ascertain the rate of refracture and to determine the subjective benefits of Activa IM-Nail™ for patients, parents and other caregivers. The study will include clinical follow-up including early post-operative complication, radiographs until bony healing and an additional follow-up after 1 year. At this stage, preliminary results and early complications on 76 patients are analyzed in this study and presented. (3) Results: As of April 2022, 76 patients were enrolled as per study protocol. There were 31 girls (40.8%) and 45 boys (59.2%). The mean age at the time of inclusion was 8.9 years (±2.4 years). The mean operation time was 58.9 ± 22.9 min (range, 15–119 min). The mean follow-up time was 8.9 ± 5.1 months (range, 0.2–18.6). Up to now, one refracture has occurred in one child falling from a height of about one meter 7 months after index surgery (1/76; 1.3%). (4) Conclusion: The research project assesses the safety and effectiveness of Activa IM-Nails™ as part of the surgical treatment of dislocated forearm fractures in children in the context of a PMCF study. The use of Activa IM-Nails™ with regard to various objectives, including postoperative complications and refracture rate, seems to be equal to the standard titan ESIN procedure compared to the literature. Preliminary results are encouraging and are made available.

Is There Room for Microsurgery in Robotic Surgery?

Robotic surgery opened a new era of minimally-invasive procedures, through its improved precision, elimination of tremors, greater degrees of freedom, and other facilitating aspects. The field of robotic microsurgery showed great growth in recent years in particular, since robotics offers a potentially-ideal configuration to perform the sensitive manipulations required in microsurgery. We conducted a systematic review to assess the benefits of robotic surgery and its contributions to microsurgery, comparing it with other surgical techniques used in patients of all age groups. We assessed 25 articles found in the PubMed and Cochrane databases using the terms ' robotic surgery ' AND microsurgery , with a filter for studies published in the last five years, and studies conducted in humans and published in English or Portuguese. We concluded that there is plenty of room for robotic surgery in microsurgery, such as in male infertility procedures, neurological microsurgery, ocular and otological surgeries, and transoral, hepatobiliary, microvascular, plastic and reconstructive surgeries.

Role of Ultrasound in the Diagnosis of Hepatocellular Carcinoma in Patients with Chronic Liver Disease

Background: Hepatocellular carcinoma (HCC) is a common cancer in humans. Its mortality ranks third among human malignancies. Cirrhosis of liver is a major contributor to hepatocellular carcinoma, about in 80% of the affected individuals. Fine needle aspiration cytology (FNAC) of the liver which is a minimal invasive procedure is essential to sort out primary and secondary neoplasm of the liver. Objective: The aim of this cross-sectional study was to determine the accuracy of ultrasound for diagnosis of HCC in comparison with FNAC findings. Materials and Methods: This study was done in the Radiology & Imaging Department in Enam Medical College & Hospital, Savar, Dhaka in collaboration with the Department of Pathology of the same institution for FNAC correlation during October 2017 to November 2019. A total number of 50 patients with CLD with known hepatic mass, referred to the department were included in the study. Ultrasound was done with TOSHIBA using low frequency curvilinear probe of 3.5 MHz. USGguided aspirations was performed using 18G needle under full aseptic measure. USG findings were validated by histopathology reports. Analysis was done by SPSS 19.0. Results: Mean age of the study population was 58.6 ± 10.9 years, of whom 37(74%) were male and 13 (26%) were female. Mean size of the hepatic lesions was 4.7 ± 1.08 cm. The lesions were characterized as iso-, hypo- and hyperechoic as compared with hepatic parenchyma. Doppler study shows both central and peripheral vascularity. Compared with FNAC findings, accuracy of USG findings was determined. Sensitivity of USG in detection of HCC was 97.7%, specificity was 66.7%, and positive prediction value 95.6% and negative prediction value 80%. Conclusion: Conventional USG can be used as a screening method in patients with CLD having hepatic masses. However, further workup is required for definite diagnosis. J Enam Med Col 2020; 10(3): 153-158

Adrenal Surgery in the Era of Multidisciplinary Endocrine Tumor Boards.

Work up of adrenal masses includes assessment of endocrine activity and malignancy risk. There is no indication for surgical removal of nonfunctional adrenal adenomas, according to the guidelines. In the present study, we aimed at evaluating the impact of a university endocrine tumor board on the quality of the indications for adrenal surgery at our institution. One hundred consecutive patients receiving primary adrenal surgery at the University Hospital of Cologne, Germany were included. Their demographics, clinic-pathologic characteristics, treatment and outcome were analyzed. In 55 (55%) cases, indication for surgery consisted in functional benign tumors, including Conn, Cushing adenomas and pheochromocytomas. Forty (40%) tumors were referred to surgery for malignancy suspicion and 5 (5%) myelolipomas were removed due to their size. Eighty-nine percent of surgeries were performed as minimally invasive procedures. Overall morbidity included two (2%) self-limiting pancreatic fistulas after left laparoscopic adrenalectomy for pheochromocytoma. All functional tumors were confirmed benign by final histology. Only 33 (82.5%) of 40 suspicious cases turned out to be malignant. Consequently, nonfunctional benign adenomas were "unnecessarily" removed in only 7 (7%) patients, with 6 (85.7%) of them having a history of extra-adrenal cancer and all of them fulfilling criteria for surgery, according to the international guidelines. In conclusion, the endocrine tumor board provided an excellent adherence to the guidelines with most surgeries being performed either for functional or malignant tumors. In nonfunctional tumors with history of extra adrenal cancer, CT guided biopsy might be considered for obviating surgery.

Research Progress in Delayed Bleeding after Endoscopic Submucosal Dissection of Early-Stage Gastrointestinal Cancer

Endoscopic submucosal dissection (ESD) has been widely used in the clinical treatment of early-stage and precancerous lesions of the digestive tract. Compared with traditional open surgery, the procedure has a number of advantages, including low postprocedural recurrence rate, the location and scope of lesions not posing much restrictions on the procedure, and quick patients recovery afterwards. The procedure has hence become one of the minimally-invasive procedures commonly performed with gastrointestinal endoscope. However, due to the influence of various factors, complications such as intraoperative and postoperative bleeding, perforation, electrocoagulation syndrome and lumen stenosis may occur. Delayed postoperative bleeding, in particular, may induce cardiovascular and other related diseases due to the insidious nature of its onset, resulting in serious consequences. It is critically important for the further development of ESD that we should acquire thorough understanding and mastery of the relevant influencing factors and preventive measures of delayed bleeding after ESD of early-stage gastrointestinal cancer. We herein summarized and discussed the latest research findings in the preventative and treatment measures.

149: CONVERSION DURING MINIMALLY INVASIVE ESOPHAGECTOMY DOES NOT AFFECT ONCOLOGICAL AND SURGICAL OUTCOMES

Abstract Background and aim We evaluated causes and implications of conversion during minimally invasive (MI) esophagectomy and the feasibility of MI surgery in patients with ‘risk indications’ that would potentially prompt the referral to open surgery. Methods We analyzed 371 patients treated with esophagectomy for cancer, between January 2016 and April 2021. We identified three groups: (I) non-MI surgery group including patients with planned open/hybrid esophagectomy (n = 26); (II) the MI surgery group including patients with totally MI procedures, both thoracoscopic/laparoscopic and robotic esophagectomy (n = 335); (III) the MI converted group with patients who had unplanned conversion (n = 10). Pre- and postoperative data were compared. ‘Risk indications’ motivating open/hybrid surgery were evaluated to define two subgroups of high- and low-risk patients treated with MI surgery, and to compare the surgical outcomes between these 2 groups. Results Overall, 345 patients were approached via MI surgery: 335 had completed MI esophagectomy (RAMIE = 63.28%; MIE = 36.72%). The conversion-rate was 2.9% (n = 10): 6.1% in MIE, 0.9% in RAMIE (P = 0.008). Postoperative leakage was higher in converted patients compared to the non-MI and the totally MI groups (P < 0.001). Surgical radicality, readmission rate and mortality were comparable. Patients with and without ‘risk indication’ for open surgery showed a similar conversion rate and post-operative outcomes following MI esophagectomy. Conclusion Conversion does not significantly affect the oncological outcomes and short-term mortality after MI esophagectomy. A MI approach could be safely offered also to patients with ‘risk indications’ that would potentially lead the choice of an open surgery.

Outcome of diaphyseal femur fractures treated with enders nail in paediatric age group

Introduction: In children, shaft femur fracture is the most common injury sustained. Earlier these fractures were treating conservatively but with advancement of orthopaedic implants and surgical modalities now operative intervention is favourable for early mobilization with less complication. Inadequate reduction/fixation can lead to growth disturbances among children about to attain skeletal maturity closure. Variety of surgical options includes external fixators, plates and flexible intramedullary nails and has its own complications, but the choice of implant to be used as gold standard in the management of these fractures is still a matter of debate. Enders nailing among the Flexible Intramedullary Nails, being a minimal invasive procedure and tensile property of the nail along with the feasibility of early mobilization led to its popularity. Aim: Aim of the study was to evaluate the use of Enders nail in paediatric diaphyseal femur fractures in terms of union, complications, early mobility and minimally invasive technique. Materials and Methods: This interventional prospective study was conducted from May 2017- April 2019 with 32 paediatric patients with diaphyseal femur fracture in a 5-15 years age group. Retrograde Enders nailing was done in all diaphyseal femur fractures using traction table.

Rare presence of foreign bodies in maxillary sinuses due to dental procedures; A retrospective case series analysis of treatment.

Introduction Displacement of foreign bodies into the maxillary sinuses during dental procedures is a rare entity. The most common causes are the iatrogenic dental procedures and the maxillofacial trauma respectively, according to the literature. The aim of this article is to present a case series of foreign bodies displacement into the maxillary sinuses due to iatrogenic dental procedures. Material and Methods Detection of the foreign bodies into the maxillary sinuses was achieved with radiologic methods and confirmed intraoperatively or later with the histopathology report. Minimal invasive procedure was the treatment of choice in all cases. Results Our study included 27 patients, 17 males and 10 females with mean age of 46.14 years (SD 10.35, range 18-65 years). The displacement of foreign bodies into the maxillary sinus concerned to fragments of teeth in 11 patients (40.27%), whole teeth in 4 (14.81%), dental implants in 5 (18.51%), dental impression materials in 2 (7.4%), endodontic treatment materials in 4 (14.80%) of which 2 associated with aspergillosis, fractured or not dental burs in 1 (3.7%). The occurrence of paranasal sinusitis due to foreign bodies displacement into the maxillary sinuses is time-dependent, the faster the treatment the better the outcome. Discussion Development of paranasal sinusitis due to displacement of foreign dental bodies into the maxillary sinuses is the physical outcome. Early surgical treatment is the key factor for to avoid sinusitis or minimize its occurrence.

Laparoscopic approach for a cesarean scar pregnancy

To describe a surgical technique of laparoscopic resection of a cesarean scar pregnancy (CSP) with an immediate myometrial reconstruction. The advantage of such a technique is that it is a minimally-invasive procedure that can treat the ectopic pregnancy and the defected scar at the same time with good postoperative results. Video article with the description of a surgical minimally-invasive technique. Academic medical center. A 34-year-old patient, Gravida 6 Para 4 Abortus 1, with a history of 4 previous cesarean sections presented to the emergency department with abdominal pain and vaginal bleeding. The patient was hemodynamically stable. An endovaginal ultrasound revealed a viable pregnancy of 8 weeks implanted in the cesarean scar, with a residual myometrium of <1 mm. Because of increasing abdominal pain, vaginal bleeding, and a desire to preserve future fertility, an emergent laparoscopy was performed. Laparoscopy was performed using a CO2 AcuPulse laser device (Lumenis Inc. Salt Lake City, Utah). A continuous wave mode was used, with a power of 30 Watt and a round-shaped beam of 1.5 mm in diameter. The laser was connected to a 10-mm Hopkins endoscope 0° (Karl Storz, Tuttlingen, Germany). A complete adhesiolysis was performed, and the urinary bladder was detached from the anterior abdominal wall. The vesicouterine fold was opened to expose the isthmic part of the uterus where the ectopic pregnancy was implanted. The defected scar was resected en bloc with the pregnancy, using the laser. The limits of the resection depended on the residual myometrial thickness. We considered a myometrial thickness of >8 mm as healthy tissue. A metallic probe was introduced vaginally into the endocervix to differentiate the anterior part from the posterior part of the uterus. This probe facilitates the manipulation of the cervix and, thus, the laparoscopic intracorporeal suturing during the myometrial reconstruction. A 2-layered suturing was performed. The first layer of the suture consisted of 3 interrupted figure-of-8 sutures using a monofilament absorbable suture (Monocryl 0, ETHICON-Johnson and Johnson medical devices New Brunswick, New Jersey). A second superficial layer consisted of a continuous nonlocking suture using the same type of thread. Laparoscopic excision of the CSP and immediate repair of the scar defect without any postoperative complications. An emergent laparoscopy was performed, with excision of the CSP and immediate reconstruction of the residual myometrium. No complications occurred, the blood loss was estimated at 200 mL, and no blood transfusion was necessary. The patient was discharged 24 hours after the intervention. Six months after surgery, the remaining myometrial thickness was between 7 mm and 9.3 mm, and no residual cesarean scar defect (isthmocele) was visualized by ultrasound. Cesarean scar pregnancy is a rare form of ectopic pregnancy. The incidence, however, is increasing as a consequence of the rising cesarean section rate. Different surgical and nonsurgical techniques have been described in the literature. Laparoscopic excision of a CSP is an effective and feasible technique with the advantage of an immediate myometrial reconstruction. The cesarean scar defect diminishes, and this potentially could improve the future fertility of the patient and decrease the probability of abnormal uterine bleeding and chronic pelvic pain.

Drainage by Direct Aspiration and Resection of a Giant Ovarian Cyst Through a Laparoscopic Minimal Invasive Procedure

Drainage by Direct Aspiration and Resection of a Giant Ovarian Cyst Through a Laparoscopic Minimal Invasive Procedure

THE OUTCOME OF ULTRASOUND GUIDED PERCUTANEOUS DRAINAGE OF LIVER ABSCESS

Introduction: Pyogenic liver abscess is aa potentially life-threatening disease with significant morbidity and mortality. Patients usually present with non-specfic symptoms initiallymaking diagnosis and treatment delayed and difficulty. Surgical drainage is associated with morbidity and mortality when compared to minimal invasive procedure and hence the study. Aims and objectives-This study was conducted with the aim to evaluate the need and the outcome of percutaneous drainage in treatment of liver abscess and also to assess the parameters during the procedure which will improve the clinical outcome. Methods- prospective observational study conducted in patients with liver abscess who were treated with ultrasound guided percutaneous catheter drainage during the study period. A total of 76 patients were studied. Results- Percutaneous catheter drainage (PCD) had 100% success rate (reduction in abscess volume by atleast 50%) with early clinical improvement and very few complications. Conclusion- Percutaneous catheter drainage of abscess is treatment of choice which is minimally invasive and also has higher success rate with earlier and better clinical and radiological improvement.

Outcomes of minimally invasive osteosynthesis of intertrochanteric fractures with dynamic hip screw: A prospective case series

BackgroundIntertrochanteric fractures are a public health concern, especially in geriatric patients. Early surgical management is crucial to allow early mobilization, which helps reduce the disability and increase patients' survival. In this article, we report the outcomes of minimally invasive osteosynthesis of intertrochanteric fractures with dynamic hip screw (DHS). MethodsThe present study was a prospective case series of patients who had intertrochanteric fractures treated with minimally invasive DHS technique. Postoperative patient satisfaction rate was evaluated using the visual analog scale (VAS) of pain. Functional outcomes were evaluated using the Harris hip score (HHS) and the Merle-d'Aubigne-Postel (MDP) scoring system at 12 months of follow-up. Satisfactory results were considered with HHS of ≥80 points and MDP scores of ≥15. Postoperative complications were noted. ResultsIn this study, 70 patients were included, 41 (58.6%) males and 29 (41.4%) females, with an average age of 69.3 ± 8.3 years. The mean length of hospital stay was 2.1 ± 0.9 days. The average follow-up period was 23.9 ± 7.1 months. The mean time to radiological union was 16.8 ± 1.9 weeks. The mean postoperative VAS score for pain was 2.5 ± 1.1. The mean HHS was 87.1 ± 4.7 points and the mean MDP score was 15.6 ± 2.3 at 12 months follow-up. An average of 10.6 ± 2.9 weeks was required for full weight bearing. ConclusionThe minimally invasive DHS technique effectively treats intertrochanteric fractures with minimal incision, less bleeding, shorter operative time, early discharge from hospital, faster rehabilitation, and favorable functional outcomes.

An integrated method for contained laparoscopic specimen removal

Efforts at minimizing pain following minimally invasive (MIS) hysterectomy were hampered by the absence of simple, reliable methods to extract specimens following the 2014 FDA safety warning discouraging power morcellation. To address this gap, an integrated method intended to provide reliable specimen containment with a multi-layer bag, segmentation using bipolar energy, and tissue extraction during laparoscopic gynecological surgical procedures was developed. This report details the pre-clinical studies demonstrating specimen containment integrity, and thermal and electrical safety of the Eximis™ CS (Contained Segmentation) Procedure. All experiments were performed in pigs and approved by the research facility's institutional animal care committee and met USDA and AAALAC guidelines. The study design was composed of three experimental groups; Bovine tongue muscle to simulate normal uterine tissue, bovine tendon draped in a “sausage casing” to simulate hard-thick myoma tissues, and a polymer block wrapped with bacon strips to simulate a severely calcified fibroid. Additionally, there were two control groups: one negative and one positive (heat gun). Each experimental group was tested in four Eximis Capture Bags (8 cuts each) for a total of 24 electromechanical cuts. Thermal evaluation of the small bowel adjacent to the capture bag during device activation was performed with a Micronor FOTEMP4-PLUS-P0-V-B fiberoptic thermometry system. Specimens were then harvested for histology and graded by a blinded pathologist using the Histopathology Scoring Criteria (edema/necrosis/inflammation); 0-4; none to marked. Electrical testing evaluated high frequency electrical leakage current by an independent laboratory with the electrosurgical generator set to 200 W output power, the maximum output setting allowable. Finally, Eximis Capture Bags were tested after segmentation using a proprietary leak test that can detect leaks < a 1 μm hole size. The test group simulating normal uterine tissue (bovine tongue) had small bowel histopathology not different from the negative control group. The calcified fibroid and myoma test groups demonstrated statistically more mucosal edema than the negative control group, but differences were not observed in the submucosa or muscularis layers that were closer to the containment bag. The Eximis Capture Bag measured leakage current directly through the bag of 1.01 mA well below the maximum allowable standard of 150 mA. No evidence of leaks was detected. These studies demonstrate that the Eximis CS is thermally and electrically safe to surrounding tissues and that tissue segmentation and extraction do not impact Eximis Capture Bag’s integrity. Clinical evaluation during human and robotic gynecologic procedures for benign disease is warranted. Additionally, these results suggest the system may be beneficial in other MIS procedures where large specimens are removed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Minimally invasive fasciotomy for symptomatic tibialis anterior muscle hernia

BackgroundSymptomatic muscle herniae are an uncommon cause of chronic exercise induced leg pain. The most common site for muscle hernia is the tibialis anterior muscle. This study evaluates the outcome of a minimal incision fasciotomy in patients with a symptomatic muscle hernia of the tibialis anterior muscle, and their return to normal daily activities including sport. MethodsThe study reports mid-term results in a series of 22 consecutive patients (17 males and 5 females, median age: 22 years) with a unilateral tibialis anterior MH who had undergone minimally invasive fasciotomy between 2008 and 2019. Clinical outcomes were assessed with SF-36 and European Quality of Life-5 Dimensions scale (EQ-5D). The ability to participate in sport before and after surgery, and the time to return to training (RTT) and to sport (RTS) were recorded. ResultsAt a median follow up after surgery of 23 months, both questionnaires showed a statistically significant improvement (P < 0.005). At the latest follow up, 16 of patients (73%) had returned to pre-injury or higher levels of sport/activity. The median time to return to training and to return to sport was 7 and 11 weeks respectively. No severe complications and no recurrence of symptoms were recorded. ConclusionMinimally invasive fasciotomy is effective and safe for patients suffering from muscle hernia of the tibialis anterior muscle with good results in the mid-term. Level of EvidenceIV.

Radioguided surgery, a useful tool for the surgical oncologist

Background: Radioguided surgery has clinical application for a variety of malignancies. Its great development in breast and melanoma has allowed its expanded use in other locations, becoming an additional tool for the surgical oncologist. It could be useful when fine needle aspiration (FNA) is non-diagnostic or not feasible or as an assistance for surgery, allowing minimal invasive procedures.

Laparoscopic adrenalectomy for metastatic disease

Background: For patients with adrenal metastasis with a limited metastatic disease called oligometastatic state, pooled analyses have shown a survival benefit for adrenal surgery, validated in endocrine and oncology guidelines. On the other hand, stereotactic radiotherapy has emerged as an efficient alternative, despite a lack of histologic proof of its efficacy. Laparoscopic adrenalectomy combines the same R0 principles as open surgery and the advantage of minimal invasive procedure in patients with decreased performance status.

Clinical and Radiographic Comparisons among Minimally Invasive Lumbar Interbody Fusion: A Comparison with Three-Way Matching.

Retrospective cohort study. To compare clinical and radiographic outcomes among minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), extreme lateral lumbar interbody fusion (XLIF), and oblique lateral lumbar interbody fusion (OLIF) techniques. To date, there are many reports comparing outcomes between MIS-TLIF and XLIF, MIS-TLIF and OLIF, or XLIF and OLIF procedures. However, there are no previous studies comparing clinical and radiographic outcomes among all these three techniques. Data from patients who underwent minimally invasive (MI) fusion surgery for lumbar degenerative diseases at L4-L5 level was analyzed. Thirty patients each from MIS-TLIF, XLIF, and OLIF groups were recruited for propensity score matching. Visual Analog Scale (VAS) of the back and legs and Oswestry Disability Index (ODI) were evaluated preoperatively and at 1, 3, and 6 months and 1 year postoperatively. Radiographic outcomes were also compared. The fusion rate was evaluated at 1 year after surgeries. The clinical outcomes were significantly improved in all groups. The disk height was significantly restored in all groups postoperatively, which was significantly more improved in XLIF and OLIF than MIS-TLIF group (p<0.001). The axial canal area was significantly increased more in MIS-TLIF versus XLIF and OLIF (p<0.001). The correction of lumbar lordotic angle and segmental sagittal angle were similar among these techniques. OLIF and XLIF groups showed less blood loss and shorter hospital stays than MIS-TLIF group (p<0.001). There was no significant difference in fusion rate among all groups. MIS-TLIF, XLIF, and OLIF facilitated safe and effective MI procedures for treating lumbar degenerative diseases. XLIF and OLIF can achieve clinical outcomes equivalent to MIS-TLIF by indirect decompression. XLIF and OLIF showed less blood loss, shorter hospital stays, and better disk and foraminal height restorations. In single-level L4-5, the restoration of sagittal alignment was similar between these three techniques.

A Minimal Invasive Surgical Procedure (Window Technique) for the Management of Sambukavrata Bhagandara (Horseshoe Shape Fistula In Ano): A Case Report

Acharya Sushruta described about Bhagandara in detail and also mentioned about treatment modalities like Kshara Sutra therapy etc. along with Kricchsadhyata difficult to treat and Asadhyata not curable of the disease. Sambukavarta Bhagandara is a Tridoshaj Bhagandara and Sushruta mentioned it as Asadhyaya disease. In contemporary science Sambukavarta Bhagandara can be correlated with horse shoe shape fistula in ano and many treatment options are available to treat the fistula in ano but still it is very challenging to treat the fistula in ano due to high recurrence rate of the disease. In this case study A 62 year old male patient came to our OPD with the complaint of Boil in perianal region along with mild pain and pus discharge since 2 years. Patient was operated previously for the same complaints before one years at somewhere but it reoccur after some time. On examination patient was diagnosed as case of Sambukavarta Bhagandara or posterior Horse shoe shape fistula in ano. In this study patient was treated by Window technique (Minimal invasive surgical procedure) along with Kshara Sutra application under local anesthesia and the outcomes of this technique were very encouraging as it was less time consuming, reduce time of hospital stay, early return to work, less postoperative pain, minimal scar tissue and minimal chances of recurrence. Hence this study is conclude that Window technique is one of the best gold standard technique for the treatment of complicated or Horse shoe shape fistula in ano.

Rhytidoplasty Through Minimal Incisions (Rhythmic).

BackgroundIn the present report, an innovative alternative approach for rhytidoplasty is described. Rhytidoplasty Through Minimal Incisions (Rhythmic) is an effective, efficient, safe, and reproducible alternative procedure for facial rejuvenation. It has several advantages over traditional procedures.ObjectiveThe main objective of this report is to describe the surgical technique of Rhythmic.MethodsThe surgical technique for the foreheadplasty requires only a transverse ~7-mm incision ~1 cm behind the hairline at the midline. The upper and lower blepharoplasty are made with incisions of ~3 mm, and no suture is needed. Liposuction of the neck can also be performed, and the face-lift can be achieved through preauricular incisions.ResultsHere, we summarize the results obtained in 741 patients subjected to rhytidoplasty through minimal incisions. The follow-up of these patients extended up to 20 years. This technique drastically reduced the length of scars; the eyebrows elevated 8-13 mm, and in some cases, the tip of the nose was also elevated ~7 mm. It minimized or eliminated the vertical frown lines and the horizontal furrows in the forehead. The use of this technique allowed an excellent definition of the cervicofacial angle in the patients.ConclusionsIn conclusion, rhytidoplasty through minimal incisions drastically reduced the length of scars, bleeding, surgical time, avoided the use of drains, reduced costs, and shorted the convalescent period. It also offered the patients a natural appearance with minor complications.Level of Evidence: 2

Minimal Incision Lower Augmentation Blepharoplasty: 3 Simple Steps to Facial Mid-Term Rejuvenation.

BackgroundThe practice of removing skin and fatty tissue from the lower eyelid does not accommodate the different forms of facial aging. Therefore, techniques that encompass the recovery of facial volumes are common. Currently, when isolated lower blepharoplasty is performed, it does not take into account that mid-face rejuvenation is simultaneously possible. Furthermore, it is not always necessary to make incisions along the entire lash line, because this may be minimal in good candidates.ObjectivesThis article presents a selection of patients who underwent augmentation lower blepharoplasty for the rejuvenation of the middle third of the face associated with the periorbital area, which is a modified traditional lower blepharoplasty technique performed with minimal incisions and fat grafting. MethodsA retrospective study was conducted on 160 patients who underwent lower augmentation blepharoplasty performed by the authors from July 2017 to March 2021. The small incision utilized is approximately 15 to 18 mm and does not reach the ends or edges of the lower eyelid. The procedure is accompanied by fat grafting in the area of the middle third of the face. Finally, a Likert test was conducted to assess satisfaction.ResultsThe patients presented a noticeable improvement, obtaining more attractive and youthful results from the middle third of the face. There were no major complications, and the patient outcomes were satisfactory.ConclusionsAugmentation lower blepharoplasty with minimal incisions can be a useful alternative for selected patients who seek to jointly rejuvenate the middle third of the face.Level of Evidence: 4