Muscle-splitting Technique Research Articles

Subfascial Mini Muscle-Release Dual Plane Technique: A Modified Procedure for Breast Augmentation.

Each breast augmentation technique has advantages and indications, and the quest for the perfect implant pocket plane is ongoing. An ideal dual plane should meet three requirements: adequate implant coverage, optimal control of breast shape, and maximal muscle preservation. This paper reports a modified procedure for breast augmentation named subfascial mini muscle-release dual plane technique. From an inframammary or periareolar approach, the implant pocket is dissected in a subfascial plane up to the pectoralis major. The muscle is split 3 cm above the lateral margin and then pocket dissection proceeds in the submuscular plane. A small portion of the costal origin is divided inferomedially creating a dual plane. A total of 178 patients with hypoplasia or breast atrophy were included, among whom 34 had breast ptosis and 20 had tubular breast deformity. The median follow-up period was 20 months. With an average implant volume of 268.8 ml and a smooth implant type of 85.4%, there was 1 case of hematoma, 2 cases of wound healing issues, 2 cases of rippling sign, 2 cases of grade III/IV capsular contracture, 5 cases of implant malposition and 12 cases of mild muscle contraction-associated deformity. Revision surgeries were performed on 2 patients. The subfascial mini muscle-release dual plane technique is an easy method for breast augmentation and is especially indicated for ptotic breasts and tubular breast deformities. This technique combines the advantages of traditional dual plane and muscle-splitting techniques, yielding a satisfactory aesthetic outcome.

"The Double S" Technique: Subfascial Dissection and Temporalis Muscle Splitting to Prevent Cerebrospinal Fluid Leak and Maximize Surgical Exposure.

Middle cranial fossa surgery commonly is approached either performing a subtemporal or a pterional craniotomy. To maximize a basitemporal region exposure, an adjunctive bone drilling could be required. In these cases, a watertight dura and temporalis muscle closure are mandatory. To describe a modified temporalis muscle dissection in middle cranial fossa surgery to increase basitemporal region exposure while assuring a safe and effective closure thus avoiding cerebrospinal fluid (CSF) leakage. A total of 8 patients have been enrolled. Five pterional and 3 subtemporal approaches were performed. In all cases, the novel subfascial muscle dissection and temporalis muscle splitting technique named "the double S technique," was performed to cut up the temporal muscle. In all cases, a subgaleal drainage was used and removed within 48 hours. No cases of postoperative CSF leak or hematoma collection were reported. The double S technique is a safe and effective alternative to enhance the basitemporal region exposure while avoiding the potential, common risk of CSF leak.

Muscle Splitting Augmentation Mastopexy: A l3-year Analysis and Outcome of Primary and Secondary Procedures.

Background:The muscle splitting technique is a submuscular pocket used for augmentation mammoplasty. Its use and results following primary and secondary procedures are presented.Methods:A retrospective study that analyzed complication and revision rates following primary and secondary mastopexy with augmentation in a muscle splitting pocket performed between April 2007 and March 2020 was carried out. Data were divided into two groups: primary and secondary single-stage mastopexies with augmentation.Results:A total of 169 patients had a primary procedure and 49 had secondary procedures. The mean ages of patients in the primary and secondary were 32.3 ± 9.89 and 38.2 ± 9.63 years, respectively. Five (3.0%) patients had periprosthetic or wound infections in the primary group when compared with 0% in secondary surgery group. Wound breakdown was seen in 13 (7.7%) patients with a primary procedure compared with one patient (2%) with a secondary procedure. One patient had partial nipple loss and another had total nipple loss in the primary group (1.2%) when compared with one patient (2.0%) who had partial nipple loss in the secondary group. Revision surgeries were carried out in 16 (10.1%) of the primary procedures compared with five (10.2%) of the secondary procedures.Conclusion:Even though there was a higher prevalence of complications in the primary procedures group than in the secondary procedures group, the overall complications following muscle splitting mastopexy with augmentation are within an acceptable range.

Minimally Invasive Posterior Cervical Discectomy: 2-Dimensional Operative Video.

Minimally invasive posterior cervical microdiscectomy is an appropriate surgical approach for patients with foraminal stenosis from herniated disc with radicular symptoms that is not responsive to conservative management. While anterior cervical discectomy and fusion (ACDF) or arthroplasty is increasingly utilized to treat herniated disc, a posterior approach eliminates the risk of potential approach related injuries to the esophagus, carotid artery, or recurrent laryngeal nerve. Additional benefits of posterior decompression include avoidance of instrumentation, which represents an increased healthcare cost, as well as potential long-term risks of adjacent-level pathologies or device failures. A traditional open posterior cervical approach has the potential to cause significant postoperative pain due to dissection of the paraspinal musculature and the potential for disrupting the posterior tension band with inadvertent injury to the interspinous ligaments. Such disadvantages are reduced by utilizing the minimally invasive technique where a small tubular working channel is placed through a muscle splitting technique via a paramedian approach. This technique minimizes the need for muscle stripping, and thus decreases postoperative functional and structural disturbance. Discectomy in this case can also be safely performed with minimal retraction at the axilla of the nerve root. Additionally, this approach can be utilized in an ambulatory setting, which coupled with the lack of any additional instrumentation helps contribute to the overall healthcare cost savings of such a procedure. This video describes how the minimally invasive posterior cervical discectomy can be effectively and safely performed in this illustrative case. The patient consented to the procedure and publication.

An overview of animation deformity in prosthetic breast reconstruction.

Animation deformity is an unsightly complication after sub-pectoral breast reconstruction characterized by implant displacement with pectoralis muscle contraction. Recent increased awareness of this phenomenon has driven interest in pre-pectoral breast reconstruction but research is limited regarding the causes and implications of animation deformity. Specifically, no patient-specific risk factors have been identified as contributing to animation deformity. Placement in a sub-pectoral plane and division of the pectoralis are the only peri-operative factors associated with severity of animation deformity. Our own quantitative analysis of animation deformity has further refined our understanding of this phenomenon, which we present here along with a review of current grading scales. We also more broadly review the current literature surrounding animation deformity, including its causes, risk factors, impact on patient outcomes and current treatment options. Overall, patients find this to be an emotionally distressing complication and most patients would like to be educated on alternative surgical options to avoid animation deformity. Treatment options range from conversion to a pre-pectoral plane to muscle-splitting techniques to selective nerve ablation to Botox injections. Further research into causes, implications and ways to enhance pre-pectoral reconstruction are needed to improve patient outcomes with this phenomenon.

Muscle-Splitting Augmentation-Mastopexy: Implant Protection With an Inferior Dermoglandular Flap.

Simultaneous augmentation-mastopexy can achieve excellent patient and surgeon satisfaction but continues to pose a challenge, with revision rates of up to 25%. Recurrent ptosis and poor overall breast shape are 2 common reasons for reoperation, whereas some of the most feared complications is breast implant exposure, infection, and loss secondary to wound breakdown; excessively large implants or too much tension during closure are possible contributing factors. We describe a technique for augmentation-mastopexy combining a muscle-splitting pocket for implant placement along with an inferior flap, which helps secure the implant in place and provides coverage in case of wound dehiscence. A retrospective chart review was performed (January 2015 to December 2017) of women who underwent augmentation-mastopexy with round, textured silicone gel implants using a muscle-splitting technique combined with an inferior de-epithelialized dermoglandular flap. A total of 118 patients (236 breasts) were operated on. Mean follow-up was 13 months (10-42 months). Mean patient age was 33.3 years (24-55 years). Mean operative time was 102.9 minutes (80-135 minutes), and implant size ranged from 175 to 350 mL (mode, 275 mL). There were no cases of implant extrusion, nipple-areola complex ischemia, or surgical site infection; however, 1 patient required revision surgery for implant malposition, and 2 had a postoperative hematoma. In summary, the technique we describe combines 2 established mammaplasty techniques, ensuring upper pole fullness with good cleavage, implant protection in case of wound breakdown, and good patient satisfaction as evidenced by a low revision rate and minimal complications. LEVEL OF EVIDENCE: IV, therapeutic. Evidence obtained from multiple time series with or without the intervention, such as case studies.

Breast animation deformity.

Breast animation deformity (BAD) has been reported to occur after submuscular implant placement following breast augmentation and immediate breast reconstruction. Despite its apparent impact on patients’ quality of life, BAD has only recently become a topic of general concern. Its incidence and etiology have yet to be established. The aim of this systematic review was to identify papers that clearly defined and classified BAD and described how the degree of animation was assessed. We performed a search in PubMed and Embase. Studies meeting the inclusion criteria that described BAD after implant-based breast augmentation or immediate breast reconstruction were included. After screening 866 publications, four studies were included: three describing BAD after breast augmentation and one describing BAD after immediate breast reconstruction. The median percentage of patients with some degree of BAD was 58%. The highest percentages were found in patients operated on using the Regnault technique or the dual-plane technique (73%–78%). The lowest percentages were found following the dual-plane muscle-splitting technique (30%) and the triple-plane technique (33%). We found no studies meeting the inclusion criteria that analyzed BAD after prepectoral implant placement. This review of the current literature suggests that the degree of BAD is proportional to the degree of muscle involvement. Evidence is scarce, and the phenomenon seems to be underreported. Future comparative studies are warranted.

Laparoscopic Appendicectomy in All Benign Pathologies of the Appendix: A retrospective study

Background: Acute appendicitis is one of the most common surgical conditions and urgent appendicectomyis recommended and practiced for more than 100 years1,2. McBurney's appendicectomy by an open muscle splitting technique was the gold standard surgical procedure1. Laparoscopic appendicectomy (LA) is gaining popularity since 1987. But this new technique has a longer learning curve and requires expensive equipment (high capital investments).The aim of this study was to ascertain the generalizability of this novel procedure when appendicectomy is indicated.Method: This study was done over a period of six years in BIRDEM. Between March 2010 to February 2016, all consecutive cases of Laparoscopic appendicectomy was selected for the study. Operation was performed under general anaesthesia using standard three puncture technique. After the procedure all resected specimen was sent for histopathology.Result: Laparoscopicappendicectomy was attempted in 113 patients, 57(50.4%) female and 56(49.6%) males. Mean age of the patients were 35.2 years and ranged from 5 to 65 years. Laparoscopicappendicectomy was performed in emergency basis in 102(90%) due to acute appendicitis, gangrenous appendix, perforated appendix or appendicular abscess. Eleven patients (10%) underwent elective surgery due to interval appendicectomy, mucocole of appendix, incidental appendicectomy. The most common indication for laparoscopic appendicectomy in this series was acute appendicitis (62%). Only one patient (<1%) had to be converted to an open appendicectomy due to injury to caecal wall. There was no peri-operative mortality in this series. Hundred and five patients (93%) weredischarged in lessthan 24 hours of surgery and seven (6%) within 48 hours of surgery after removal of intrabdominal drain. Follow-up period was one month to two years.Conclusion: All the advantages of laparoscopy are well applied in laparoscopic appendicectomy. Morbidity, mortality and conversion rate came down to a minimum with time and experience. Hence laparoscopic appendicectomy should be the procedure of choice when appendicectomy in indicated.Bangladesh Crit Care J September 2018; 6(2): 80-83

Atypical anatomy associated with a lumbar far lateral disc herniation

Abstract Far lateral disc herniation is an uncommon but potentially significant cause of intractable leg pain associated with compression of the exiting nerve root and associated dorsal root ganglion. Since far lateral disc herniations are located outside the spinal canal, several minimally invasive paraspinal muscle-splitting techniques have been developed that allow for neural decompression with reduced soft tissue and bony trauma compared with conventional midline approaches. However, minimally invasive approaches require familiarity with the microsurgical anatomy of the extra-foraminal compartment because of the limited exposure. We report a case of an atypical anatomic relationship identified during far lateral discectomy involving a disc fragment located in a superolateral location relative to the exiting nerve root rather than the more common inferomedial location. This report highlights that familiarity with atypical locations of an extra-foraminal disc herniation and careful exploration of all quadrants in the surgical field is important during minimally invasive far lateral discectomy.

A minimal access far-lateral approach to foramen magnum lesions.

Objectives The far-lateral approach is widely used to treat pathology of the ventral foramen magnum. Numerous methods of exposure have been described, most of which utilize long skin incisions and myocutaneous flaps. Here we present our experience with gaining exposure through a small paramedian incision using a muscle-splitting technique. Design A cadaveric anatomical study was first performed to verify the feasibility of the approach. We then describe our experience with using the approach in 13 patients. A retrospective chart review was performed and data regarding pathology, imaging, and complications were collected. Results The cadaveric study confirmed that a small paramedian muscle-splitting approach allows sufficient exposure to approach many foramen magnum lesions. Our case series included 10 patients with meningioma, one brainstem glioblastoma, one posterior inferior cerebellar artery aneurysm, and one odontoid pannus. The exposure was adequate in all cases. For the meningioma patients, six had gross total resections and four had subtotal resection because of tumor adherence to neurovascular structures. Two patients experienced postoperative cardiovascular complications. There were no new neurologic deficits, cerebrospinal fluid leaks, or wound complications. Conclusions A small paramedian incision may be used to gain exposure and perform successful far-lateral approaches. The small exposure is likely to reduce the risk of local complications such as cerebrospinal fluid fistula and pseudomeningocele when compared with larger exposures.

Single-Site Retroperitoneoscopic Donor Nephrectomy

We have performed retroperitoneoscopic nephrectomy for living kidney donor surgery since 2000. Recently, we introduced single–site retroperitoneoscopic donor nephrectomy (RDN) as a less invasive donor surgery. The procedure was performed in 7 donors (5 women and 2 men) by a single surgeon. The mean age and body mass index of the donors were 62.6 years (range, 53–74 years) and 24.3 kg/m2 (range, 22.3–29.0 kg/m2), respectively. Left-sided nephrectomy was performed in all the donors. The donors were positioned in the right lateral position, and a 7-cm-long incision was made in the left flank. The incision was extended to the retroperitoneal space using the muscle-splitting technique. The retroperitoneal space was then expanded using an inflation balloon. A GelPOINT Advanced Access Platform (Applied Medical, Rancho Santa Margarita, Calif, United States) was placed in the incision. The subsequent technique and equipment were the same as those used in conventional 3-port RDN. The renal artery and vein were dissected using a vascular stapler, and the kidney graft was directly extracted through the incision. The mean operative time was 197 ± 28 minutes, warm ischemic time was 4.1 ± 1.2 minutes, and blood loss was 75 ± 113 mL. No statistical differences were found between the present method and conventional 3-port RDN. Intraoperative and postoperative complications were not observed in any of the donors. Graft function after transplantation was good, and delayed graft function was not observed in any of the recipients. This technique can be easily introduced in the clinical setting by surgeons experienced in RDN.

Minimally invasive approach for the treatment of intradural spinal pathology

A wide variety of spinal intradural pathology traditionally has been treated from a midline posterior laminectomy using standard microsurgical techniques. This approach has been successful in treating the pathology; however, it carries a risk of postoperative complications including CSF leakage, wound infection, and spinal instability. The authors describe a minimally invasive surgical (MIS) approach to treating spinal intradural pathology with a low rate of postoperative complications. Through a retrospective review of a prospectively collected surgical database, the authors identified 26 patients who underwent 27 surgeries via an MIS approach for intradural pathology of the spine. Using a tubular retractor system and an operative microscope, the authors were able to treat all patients with a unilateral, paramedian, and muscle-splitting technique. They then collected data regarding operative blood loss, length of stay, imaging characteristics, and outcomes. Eight cervical, 8 thoracic, and 11 lumbar intradural pathological entities, which included 14 oncological lesions, 4 Chiari I malformations, 4 arachnoid cysts, 3 tethered cords, 1 syrinx, and 1 chronic visceral pain, were treated via an MIS approach. The average blood loss was 197 ml and the average hospital stay was 3 days. One patient had to return to the operating room for noninfectious wound dehiscence. One patient required reoperation 18 months after the initial surgery for recurrence of the initial pathology. There was no CSF leak, no infection, and no spinal instability associated with the initial surgery on follow-up. Intradural spinal pathology can be safely and effectively treated with MIS approaches without an increased risk of neurological injury. This approach may also offer a reduced postoperative length of stay, risk of CSF leak, and risk of future spinal instability.

Transaxillary Muscle-Splitting Breast Augmentation: Experience with 160 Cases

Muscle-splitting breast augmentation, initially described by Baxter and later popularized by Khan, has proved to be an effective technique in terms of implant coverage, bypassing, and even solving of some issues associated with the dual-plane technique. A muscle-splitting breast augmentation technique recently has been used in combination with mastopexy. However, no reports have described muscle-splitting techniques accomplished by the transaxillary route. A prospective study was conducted to evaluate the outcomes and complications of a novel approach to a specific breast augmentation technique. A total of 160 patients underwent bilateral transaxillary muscle-splitting breast augmentation between October 2007 and July 2010. All the patients were treated on an outpatient basis and received epidural anesthesia. Soft, round, textured, cohesive gel implants ranging in size from 200 to 350 ml were used. All the patients recovered quickly. To date, no infection, capsular contracture, rippling, double-bubble deformity, muscle contracture-associated deformities, or implant migration has occurred. Four patients (2.5%) experienced hematomas, all of which resolved before discharge. All the patients were discharged less than 24 h postoperatively and had an aesthetically natural result. Transaxillary muscle-splitting breast augmentation, a novel approach to a technique that has been described previously, provides consistent, satisfactory results and good reproducibility. This new approach provides an excellent anatomic final appearance with no risk of displacement, rippling, double-bubble deformity, or contracture-associated deformities. Furthermore, this technique avoids any visible scars on the breast and features a low complication rate.

Simultaneous Acute Rotator Cuff Tear and Distal Biceps Rupture in a Strongman Competitor

Acute rotator cuff tear is commonly associated with tearing of the proximal biceps tendon, but has never been reported to occur simultaneously with a distal biceps tendon rupture. A 38-year-old right-hand-dominant strongman competitor attempted a 300-pound overhead axle press and experienced immediate pain in the right shoulder and elbow. He had no known systemic risk factors for tendon ruptures including hyperparathyroidism, hemodialysis, alcoholism, rheumatoid arthritis, statin medications, fluoroquinolones, and steroid use.Right shoulder magnetic resonance imaging (MRI) showed a full-thickness supraspinatus tear with 3 cm of retraction. There was minimal fatty infiltration of the supraspinatus on the sagittal cuts consistent with acute rupture. The subscapularis was intact. The long head of the biceps tendon had mild medial subluxation but was completely within the bicipital groove. Right elbow MRI showed a complete distal biceps tendon rupture. Thirteen days after his injury, the patient underwent arthroscopic supraspinatus repair and proximal biceps tenodesis. Distal biceps tendon repair was performed using the modified 2-incision muscle-splitting technique. At 24-month follow-up, the patient was pain free and had returned to full activity including weightlifting but had not returned to strongman competition.This is the first report of simultaneous acute full thickness ruptures of the rotator cuff and distal biceps tendon. This case report underscores the importance of a complete physical examination and a high index of suspicion for additional concomitant injuries, particularly in athletes with unusually high stresses to the body.

Minimally invasive endoscopic-assisted posterior thoracic sympathectomy

Palmar hyperhidrosis is a disorder of the autonomic nervous system characterized by excessive perspiration of the palms, but may involve other body parts as well. Traditional posterior approaches have been performed less often in favor of less invasive thoracoscopic sympathectomies, which have a high success rate with low associated morbidity. However, some patients are not candidates for a transthoracic surgery and may need an alternative treatment strategy. In situations in which a posterior approach may be necessary, the authors have developed a minimal access endoscopic-assisted dorsal sympathectomy procedure, applying minimally invasive spine muscle splitting techniques. The authors believe that the development of this technique may help to minimize surgical morbidity associated with the traditional posterior approach by reducing pain, tissue damage, and length of postoperative recovery. This paper is a report on the successful treatment of palmar hyperhidrosis using a minimally invasive posterior technique and describes the surgical approach and outcomes in 2 patients who have been treated in this manner. Two patients underwent minimally invasive endoscopic-assisted posterior thoracic sympathectomy for hyperhidrosis. Both patients experienced relief of their symptoms after surgery with follow-up durations of 32 and 9 months and length of stays of 0.9 and 2.8 days, respectively. One patient suffered a unilateral Horner syndrome and underwent an eyelid lift. The other patient was readmitted to the hospital 2 days after discharge with atelectasis. She was obese and suffered from chronic obstructive pulmonary disease at baseline, which were reasons she opted for a posterior approach. Neither patient suffered a pneumo- or hemothorax. Minimally invasive endoscopic-assisted posterior thoracic sympathectomy can be safely performed for relief of hyperhidrosis. The procedure has risks for the usual complications of sympathectomy. This technique may provide an alternative to thoracoscopic approaches, especially in those patients with pulmonary disease or obesity.

Experience with a nonlaparoscopic, transumbilical, intracavitary pyloromyotomy

Background/PurposeRamstedt's pyloromyotomy for hypertrophic pyloric stenosis is elegant, effective, and time-honored. Although its basic principle has not changed over the last 95 years, considerable debate exists concerning the preferred access to the pylorus and the muscle-splitting technique. Reviewed here is the experience with an approach that combines the ease and safety of the “open” pyloromyotomy with the advantages of minimal invasiveness. MethodsThis series encompasses 75 consecutive, prospectively recorded pyloromyotomies. A short, curved upper umbilical rim incision is made. The linea alba is transected transversally and the abdomen entered. The pylorus is grasped with a Babcock clamp and lifted to the incision, but not delivered. Two 3:0 guy sutures are placed in the hypertrophied musculature to lift and maintain the pylorus in place. A longitudinal serosal incision is made and deepened to 1 to 3 mm. Two double-pronged skin hooks are placed, one on each partially separated edge, and gentle upward and outward traction applied until complete splitting is achieved. The mucosa is not touched by an instrument. ResultsThe age of the 75 children ranged from 9 to 89 days (mean, 40; median, 36). Their weight ranged from 2.4 to 5.4 kg (mean, 3.7 kg; median, 3.6). Fifty-seven were boys. The mean operating time was 28 minutes. The pyloric muscle splitting was performed by general surgical residents in 66. There were no mucosal injuries. Seventy-two children were discharged within 24 hours, the remaining within 48 hours. Two superficial wound infections and one suture reaction occurred. There were no recurrences. ConclusionTransumbilical intracavitary pyloromyotomy is a safe, reproducible procedure combining the advantages of the two most commonly employed approaches (traditional “open” and laparoscopic). Because the pylorus is not delivered, a smaller incision is used. The scar is virtually invisible. The safety of this procedure renders it well suited for the teaching setting.

Muscle-Splitting Breast Augmentation: A New Pocket in a Different Plane

Breast augmentation usually is performed in subglandular, subfascial, or partial submuscular pockets, including the dual plane. A new pocket has been described and used by the author. The initial pocket was made in the subglandular plane up to the lower level of the nipple-areolar complex, and the submuscular plane was reached by splitting the pectoralis major muscle without its release from the costal margin. The implant lies in this plane simultaneously behind and in front of the pectoralis. From October 2005 to November 2006, 125 patients underwent bilateral breast augmentation using the new technique. Soft cohesive gel microtextured round implants ranging in size from 230 to 440 ml were used. All the patients experienced a quick recovery with three-dimensional enhancement and having the benefits of both subglandular and submuscular planes. No rippling, lateral displacement, double-bubble deformity, or muscle contraction-associated deformities were seen. All the patients had aesthetically natural cleavage, with the nipple at the most projected part of the breast. Postoperative analgesia requirements were reduced because of dissection in natural planes. For adequate cover of the prosthesis, only the upper part of the pectoralis major muscle is required. This can be achieved by using the pectoralis muscle-splitting technique. The pectoralis major was split in the direction of its fibers, avoiding extensive muscle release. Surgical morbidity was reduced, resulting in a quick postoperative recovery and a more natural three-dimensional appearance of the breast.

Mini-laparotomy cholecystectomy: Technique, outcomes: A prospective study

Background The last decades have been characterized by a rapid growth in minimally invasive techniques for acute and chronic cholecystitis. The aim of our study was to analyze 10 years of experience with the mini-laparotomy cholecystectomy. Methods From 1994 to 2004, we performed 2295 mini-laparotomy cholecystectomies, including 1028 patients with acute and 1267 patients with chronic cholecystitis. There were 1780 women and 515 men. We utilized a special surgical tool kit with a system of circular and small hook-retractors incorporating an illuminator and long surgical instruments. Our surgical approach was carried out using a 3–5 cm longitudinal incision located immediately above the gallbladder with a muscle splitting technique. Results The mean time of operation was 64.5 ± 24.5 min and the conversion rate was 3.7%. Intraoperative complications occurred in 25 cases (1.1%), including 4 cases (0.17%) of biliary tract injury. Cholecystectomy was combined with intervention on the choledochus and the papilla of Vater in 133 patients with choledocholithiasis. Postoperative complications developed in 4.1%. Five hundred and five patients (22%) required opioid analgesics on the first postoperative day. The mortality rate was 0.17%. The mortalities involved patients who had severe concomitant diseases and required urgent surgery for acute cholecystitis. Patients operated for acute cholecystitis had significantly higher rates of postoperative complications (5.8% vs. 2.8%), need for opioids (25.5% vs. 19.2%) and mortality (0.39% vs. 0%). Conclusions Mini-laparotomy cholecystectomy is an alternative to laparoscopic approach in the surgical treatment of acute and chronic cholecystitis.

Posterior approach technique for accessory‐suprascapular nerve transfer: A cadaveric study of the anatomical landmarks and number of myelinated axons

Accessory-suprascapular nerve transfer by the anterior supraclavicular approach technique was suggested to ensure transferrance of the spinal accessory nerve to healthy recipients. However, a double crush lesion of the suprascapular nerve might not be sufficiently demonstrated. In that case, accessory-suprascapular nerve transfer by the posterior approach would probably solve the problem. The aim of this study was to evaluate the anatomical landmarks and histomorphometry of the spinal accessory and suprascapular nerve in the posterior approach. Dissection of fresh cadaveric shoulder in a prone position identified the spinal accessory and suprascapular nerve by the trapezius muscle splitting technique. After that, nerves were taken for histomorphometric evaluation. The spinal accessory nerve was located approximately halfway between the spinous process and conoid tubercle. The average distance from the conoid tubercle to the suprascapular nerve (medial edge of the suprascapular notch) is 3.3 cm. The mean number of myelinated axons of the spinal accessory and suprascapular nerve was 1,603 and 6,004 axons, respectively. The results of this study supported the brachial plexus reconstructive surgeons, who carry out accessory-suprascapular nerve transfer by using the posterior approach technique. This technique is an alternative for patients who have severe crushed injury of the shoulder or suspected double crush lesion of the suprascapular nerve.

Prevention of axillary nerve injury in anterior shoulder reconstructions: use of a subscapularis muscle-splitting technique and a review of the literature.

Previous authors have suggested that the axillary nerve should be explored or palpated during all anterior shoulder stabilization procedures. The goal of this study was to document the axillary nerve injury rate in a cohort of patients who had undergone anterior shoulder stabilization without axillary nerve dissection. Use of a subscapularis muscle-splitting approach by using a retractor along the scapular neck does not result in significant risk of injury to the axillary nerve, and exploration of the axillary nerve is not necessary using this approach. Prospective cohort study. One hundred and twenty-eight anterior stabilizations were performed with a subscapularis muscle-splitting approach that has been previously described. In all cases a retractor was placed along the inferior scapular neck to protect the axillary nerve. The axillary nerve was not exposed or palpated in any case. All patients were evaluated on the 1st postoperative day and again within 10 days for symptoms of axillary nerve palsy, including sensory loss and return of muscle function. One patient (0.8%) had paresthesia in an axillary nerve distribution; recovery occurred without the need for electromyography or other interventions. There were no clinically detected cases of axillary nerve motor dysfunction. Routine exposure of the axillary nerve is not necessary during anterior stabilization procedures using a subscapularis muscle-splitting approach if proper precautions are taken to protect the nerve. Other techniques of anterior stabilization may require exposure of the axillary nerve.