Surgery Research Articles

Management of Miller’s Class-III multiple recession defects in mandibular anterior teeth using vista technique and PRF membrane: A case report

Gingival recession, characterized by the displacement of gingival tissue towards the root surface, poses challenges like compromised aesthetics and heightened vulnerability to dental issues such as root caries and sensitivity. Various surgical techniques have been developed to address these concerns, with recent advancements like the Vestibular Incision Subperiosteal Tunnel Access (VISTA) technique showing promise, especially for multiple recession defects in the esthetic zone. VISTA reduces tissue trauma and promotes optimal healing by minimizing micromotion, thus enhancing the overall success of root coverage procedures. Integrating Platelet-rich fibrin (PRF) membranes aids in soft tissue healing and graft integration, offering a cost-effective and immune-friendly option to bolster procedure success.In a 31-year-old female patient with receding gums and mobile teeth, vestibuloplasty was performed after oral prophylaxis and stabilization of mobile teeth to address the inadequate vestibular depth and mucogingival deformity. Post-operative care included antibiotics and pain relief medications. Subsequently, a Miller’s Class-III multiple gingival defect (MRD) was corrected using the VISTA technique combined with Platelet-rich fibrin (PRF) membrane application. PRF was inserted into the tunnel to cover the denuded roots and to improve the gingival phenotype and the surgical site was sutured. One month later, successful healing was evident with increased vestibular depth, demonstrating effective treatment outcomes.

Pediatric-Specific Lesions in Unstable Pelvic Ring Fractures of Skeletally Immature Children: Impact on Diagnosis and Management Decisions.

Surgical fixation of pediatric pelvic ring injuries is gaining popularity to avoid the poor long-term outcomes of pelvic asymmetry. The surgical techniques and fixation choices depend on the individual injuries affecting the anterior and posterior pelvic ring areas. The immature bony pelvis of young children has anatomic differences including soft bones, elastic ligaments, and the presence of growth centers. Understanding the unique pediatric lesions with unstable pelvic fractures is essential for treatment decisions. Anterior lesions include pubic symphysis disruption through the pubic apophysis, single ramus fractures, pubic rami fractures through the triradiate cartilage, and/or the ischiopubic synchondrosis; ischiopubic ramus infolding injury; or the unstable superior and inferior quadrant lesions. Posterior pelvic lesions include iliac wing infolding and sacroiliac joint dislocation or transiliac (crescent) fracture/dislocations through the iliac apophysis growth plate. Pubic symphysis and sacroiliac disruptions are physeal injuries in children, and they have excellent healing potential. External fixation is an ideal choice for anterior ring fixation including bony and pubic symphysis injuries. Posterior lesions are mostly sacroiliac joint disruptions with iliac apophysis separation that can serve as a landmark for vertical displacement correction. Posterior lesions can be treated by percutaneous iliosacral screw fixation or open reduction techniques.

A comparative study of functional outcome of percutaneous kirschner wire fixation versus philos plating of proximal humerus fractures

: Proximal humerus fractures, accounting for approximately 5% of all fractures, pose a significant challenge in orthopedic management due to their complex anatomy and diverse fracture patterns. Treatment options range from conservative methods to various surgical interventions, each with its pros and cons. This study specifically compares two commonly employed surgical techniques: Open reduction & internal fixation with PHILOS plate and percutaneous k-wire fixation with/without external clamps. This study aims to address the effectiveness of each technique by evaluating functional outcomes using validated scoring systems like the Constant-Murley Score. To assess the functional outcomes of two surgical treatment methods (K-wire application and PHILOS plate fixation) for proximal humerus fractures. : A randomized prospective study was conducted on patients coming to the Orthopaedics outpatient department or casualty of tertiary care hospital for a duration of 1 year from Dec 2022 to Nov 2023. A total of 18 patients were included in the study. The mean Constant- Murley Score (CMS) was 81 +/- 6.13 for the PHILOS plating group and 76.88 +/- 7.37 for the K-wire treated group with a p-value of 0.08. The results for CMS were excellent in 22.2% of patients and good in 66.7% of patients in PHILOS treated group and excellent for 11.11%, good for 66.67% and satisfactory for 22.2% in the K-wire treated group. Both groups achieved satisfactory functional outcomes with CM Score at the final follow-up. Both techniques achieved favorable outcomes, with a majority of patients in both groups (88.89% for PHILOS and 77.78% for K-wire) achieving good to excellent results based on the CMS scores.

Prosthodontic criteria for maxillary immediate occlusal loading, surgical classifications of atrophic maxillae, and presentation of a new implant/anatomic classification system for immediate maxillary rehabilitation.

Immediate full-arch occlusal loading for patients with atrophic edentulous maxillae satisfies critical needs for this specific type of edentulous patient after placement of implants with high levels of primary implant stability. The needs include improved aesthetics, limited immediate improved function, and elimination of removable prostheses. Classification systems exist for edentulous maxillae but they do not include specifics regarding posterior implant placement. In conjunction with anterior implants, posterior implants improve Anterior/Posterior (A/P) spreads, decrease cantilevered segments (CLs), and likely will improve implant and prosthetic success rates. The purposes of this article include presenting a new classification system that outlines the different types of implants now available which will likely achieve the requisite primary stability for immediate fixed rehabilitation. This proposed classification system identifies a relationship between different implant options currently available and the remaining quantity of bone in the first and second maxillary molar zones. The available literature regarding current classification systems was reviewed. The benefits and limitations of each system were described. The parameters associated with Immediate Occlusal Loading (IOL) for full arch maxillary prostheses include: posterior cantilever lengths of full arch fixed prostheses; existing A/P spread considerations for full arch prostheses; and introduction of a new classification system for atrophic posterior maxillary edentulous ridges were identified. Currently, there are no available classification systems that outline specific implant options for posterior maxillae which will likely achieve the minimum primary stability needed for immediate rehabilitation. A new classification system was proposed where the rationale was to show clinicians that when a certain amount of bone remains in the posterior maxilla, there are specific implants designed to maximize primary stability. High implant primary stability is required for rehabilitation with immediate fixed implant-supported provisional prostheses. The proposed classification system assists clinicians in understanding what implant geometry is available and can be expected to achieve the requisite primary stability for immediate occlusal loading based on the available bone in the posterior maxillary molar zone. This article reviewed current classification systems for edentulous maxillary patients, as well as clinical parameters required for full arch, immediate occlusal loading. It also presented a new classification system to assist clinicians in selecting appropriate implants and surgical techniques for immediate fixed rehabilitation of patients with atrophic maxillae.

The meniscotibial ligament does exist: An anatomic and histological description

PurposeTo describe the anatomical and histological characteristics of the human MTL (meniscotibial ligament) that keeps the meniscus stable and are rarely discussed. Study designDescriptive laboratory study. MethodsIn total, six fresh-frozen adult cadaver knees were dissected, and the dissection protocol were designed by two experienced anatomy professors. The anatomical morphology of MTL was observed. The main anatomical specimens included meniscus, tibial plateau, MTL. The osteotome was used to excise the portion of the tibial plateau, which could obtain the complex including partial meniscus, MTL, and a tibial fragment. A histopathologic study was performed by two experienced pathologists. ResultsMacroscopically, the MTL could be divided into two parts: medial meniscotibial ligament (MMTL)and lateral meniscotibial ligament (LMTL). The MMTL is distributed continuously, whereas the LMTL is discontinuous on the tibial plateau. The average length from the tibial attachment of the LMTL to the articular surface was 19 ± 1.0mm (mean ± SD). The average length from the tibial attachment of the MMTL to the articular surface was 10 ± 1.2 mm (mean ± SD). Microscopy of the MTL showed that the MTL is a ligamentous tissue, composed of a network of oriented collagenous fibers. ConclusionsIn all knees, the MTL was inserted on the outer edge of the meniscus, attaching to the tibia below the level of articular cartilage, which was key to maintaining the rotational stability of knee and the meniscus in the physiological position on the tibial plateau. Histological analysis of this ligament demonstrated that the MTL is a veritable ligamentous structure, which is made up of collagen type I–expressing fibroblasts. Clinical relevanceThis article contributes to the understanding of the anatomical and histological characteristics of the MTL. It is beneficial to promote the development of relevant surgical techniques for the MTL lesion.

Improvements and challenges in intraperitoneal laparoscopic para-aortic lymphadenectomy: The novel "tent-pitching" antegrade approach and vascular anatomical variations in the para-aortic region.

This study introduces and compares a new intraperitoneal laparoscopic para-aortic lymphadenectomy method to reach the level of the renal vein, the "tent-pitching" antegrade approach with the retrograde approach in gynecological malignancy surgeries in terms of success rate, complication incidence, and the number of lymph nodes removed. It focuses on the feasibility, safety, and effectiveness. Meanwhile, this article reports on the vascular anatomical variations discovered in the para-aortic region to enhance surgical safety. This was a retrospective cohort study including patients undergone laparoscopic para-aortic lymphadenectomy at a single center from January 2020 to December 2023 for high-risk endometrial and early-stage ovarian cancer. Patient charts were reviewed for mode of operation, perioperative complications, operative details, and histopathology. The patients were divided into anterograde group and retrograde group according to the operation mode. The two groups were further compared based on the success rate of lymph node clearance at the renal vein level, perioperative complications, and the number of removed lymph nodes. Quantitative data were analyzed using the t-test, non-normally distributed data using the rank-sum test, and categorical data using Fisher's exact test and the chi-square test, with statistical significance defined as P < 0.05. Among 173 patients, the antegrade group showed higher surgery success (97.5% vs 68.82%), more lymph nodes removed (median 14 vs 7), and less median blood loss. The operation time was shorter in the antegrade group. Postoperative complications like lymphocele and venous thrombosis were lower in the antegrade group. Vascular abnormalities were found in 28.9% of patients, with accessory lumbar vein routing anomaly and accessory renal arteries being most common. The antegrade approach is feasible, safe, and effective, improving surgical exposure, reducing difficulty without additional instruments or puncture sites, and minimizing organ damage risk. It is effective in achieving better access to the renal vein and removing more para-aortic lymph nodes than the retrograde method. Recognizing and carefully managing the diverse vascular abnormalities in the para-aortic area, including variations in renal arteries, veins, and the inferior vena cava, is essential to reduce intraoperative bleeding and the likelihood of converting to open surgery.

Comparison of microscopic full-laminectomy (open surgery) and microendoscopic minimally invasive hemilaminectomy for thoracic extramedullary spinal tumours

BackgroundMinimally invasive treatments for spinal cord tumours are common. The aim of this study was to compare the perioperative outcomes of patients with thoracic extramedullary spinal tumours (TEST) treated by microendoscopic minimally invasive surgery—hemilaminectomy through a homemade tubular retractor (MIS-TR) and microscopic full laminectomy (open surgery).MethodsBetween February 2016 and February 2021, 51 patients with TEST were included. According to their clinical data, patients were classified into the MIS-TR group (n = 30) and the open surgery group (n = 21) and assessed.ResultsIn both groups, the mean operation time, change in perioperative ASIA score, and modified Macnab score were comparable. The average postoperative hospital stay in the MIS-TR group was substantially shorter than that in the open surgery group (p < 0.0001). The mean blood loss volume in the MIS-TR group was substantially lower than that in the open surgery group (p = 0.001). The perioperative complication rate in the MIS-TR group was considerably lower than that in the open surgery group (p < 0.0001). At the 3-month follow-up, there was no substantial difference in the Oswestry Disability Index (ODI) score improvement between the two groups. Nonetheless, at the 12-month follow-up, the average ODI in the MIS-TR group was considerably lower than that in the open surgery group (p = 0.023). The main influencing factors for complete postoperative recovery were preoperative ASIA score (OR 7.848, P = 0.002), surgical complications (OR 0.017, P = 0.008) and age (OR 0.974, P = 0.393).ConclusionsMIS-TR is safer and more effective than open surgery for treating TEST, but the long-term recovery of MIS-TR is not better than that of open surgery.

Comparison of endoscopic and microscopic stapedotomy in the same patients: a prospective randomized controlled trial.

This study aimed to conduct a comparative analysis of audiological and postoperative clinical outcomes between the endoscopic and microscopic stapedotomy approaches. This study employed a randomized, controlled design. Twenty-seven patients with bilateral otosclerosis underwent stapedotomy in both ears, with randomized allocation of the surgical technique (endoscopic vs. microscopic) for the first operated ear. Air-bone gap (ABG) and ABG gain were measured at least 12 months postoperatively. Postoperative outcomes including pain (Visual Analog Scale-VAS), dizziness, early-term (day 1) and late-term (6 months) dysgeusia were evaluated. The Glasgow Benefit Inventory (GBI) assessed health-related quality of life at one month postoperatively, and operative time was measured. This study compared endoscopic (n = 27 ears) and microscopic (n = 27 ears) stapedotomy for otosclerosis. Both groups achieved similar hearing improvement with no significant differences in pre-operative and post-operative bone/air conduction thresholds, ABG, and ABG gain (all p > 0.05). The endoscopic stapedotomy group demonstrated reduced postoperative pain (lower VAS scores, p < 0.001), lower early dysgeusia (3.7% vs. 33.3%, p = 0.005), shorter operative time (47.3 vs. 75.4min, p < 0.001) and improved patient-reported outcomes (higher GBI score, p = 0.014) when compared to microscopic stapedotomy group. No significant differences were observed in postoperative dizziness or late-term dysgeusia between groups. This study found similar hearing improvement with both endoscopic and microscopic stapedotomy for otosclerosis. However, the endoscopic approach showed advantages in reduced postoperative pain, early dysgeusia, and operative time, with improved patient-reported quality of life. These findings suggest endoscopic stapedotomy as a valuable alternative to the conventional microscopic approach.

Modifications of surgical techniques in laparoscopic percutaneous extraperitoneal closure of inguinal ring for childhood inguinal hernia to achieve zero recurrence and zero subcutaneous stitch granuloma.

To present our technical modifications of single incision laparoscopic percutaneous extraperitoneal closure (SILPEC) of the internal inguinal ring (IIR) for pediatric inguinal hernia (PIH). The prospectively collected data of all children diagnosed with PIH undergoing SILPEC at our center from 2016 to 2023 were reviewed and divided into two groups for result comparison: Group A: before and Group B: after the implementation of full modifications. Our modifications included using a nonabsorbable monofilament suture, creating a peritoneal thermal injury at the internal inguinal ring (IIR), employing a cannula to ensure the suture at the IIR ligates only the peritoneum, and double ligation of the IIR in selected cases. 1755 patients in group A and in group B (1 month to 14 years old) were enrolled. There were no significant differences regarding baseline patient characteristics between the two groups. At a median follow-up of 40 months, the rate of recurrent CIH and subcutaneous stitch granuloma (SSG) was 2.3% and 1.5% in group A vs. 0% and 0% in group B (p < 0.001). There were no hydroceles, no ascended or atrophic testis. Our SILPEC technical modifications can achieve zero recurrence and zero SSG for PIH.

Comparison of outcomes after unplanned conversion for patients undergoing robotic when compared with laparoscopic colectomy.

The robotic approach improves the feasibility of minimally invasive colectomy even where there may be an anatomic challenge with laparoscopy. Whether a failure in completing colectomy with this newer technology is associated with worse consequences needs to be considered when evaluating the relative benefit of robotic colectomy. The aim of this study is to evaluate rates of conversion to open surgery after robotic and laparoscopic colectomy and whether outcomes after conversion vary after the two techniques since this has not been well studied. From the American College of Surgeons (ACS) - National Surgical Quality Improvement Program (NSQIP) (2015-2016), patients who underwent elective minimally invasive colectomy were identified. Converted robotic were compared to laparoscopic procedures for patient demographics, co-morbidities; primary procedure and diagnosis, prolonged operation and postoperative complications. Of 36,046 colectomy procedures, 30,808 (85.5%) were laparoscopic, while 5238 (14.5%) were robotic-assisted. There were 3271 (9.1%) conversions to open surgery (laparoscopic: 2959 [9.6%]; robotic: 312 [6%]). Thirty-day postoperative surgical site infection, anastomotic leak, ileus, sepsis, bleeding requiring transfusion, urinary tract infection, reoperation; pulmonary, renal, cardiac/cerebrovascular complications; readmission, hospital stay, and mortality, were similar between the two groups. However, deep vein thrombosis/pulmonary embolism was higher after robotic conversion (4.5% vs. 2.2%, p = 0.01). Conversion was lower after robotic when compared to laparoscopic colectomy. Converted patients had similar outcomes except for vein thromboembolism which was higher after robotic surgery. Robotic technology seems to improve the feasibility of minimally invasive surgery without negatively affecting safety and efficacy even when conversion is required.

American Rhinologic Society Expert Practice Statement: Indications and Recommendations for Septoplasty in Children.

The goal of this American Rhinologic Society Expert Practice Statement (EPS) is to provide recommendations and guidance through evidence-based consensus statements regarding pediatric septoplasty. This EPS was developed following the previously published methodology and approval process. The topics of interest included appropriate indications, safety and efficacy, timing, relevant quality of life instruments, and surgical techniques. Following a modified Delphi approach, six statements were developed, five of which reached consensus and one that did not. These statements and accompanying evidence are summarized along with an assessment of future needs.

Microsurgical Management of Complex Meningiomas Involving Dural Venous Sinuses: Operative Techniques, Case Illustrations and Long-Term Outcomes in a Series of 70 Cases

BackgroundMeningiomas involving the dural venous sinuses present unique therapeutic challenges. While gross total resection remains the mainstay of treatment for meningiomas, involvement of critical vascular structures may limit extent of resection and increase the risk of recurrence. Optimal management of meningiomas with venous sinus involvement has been discussed in the literature, with some advocating for subtotal resection with post-operative surveillance and radiation, if necessary, while others recommend total resection with reconstruction of resection of the involved sinus. MethodsWe performed a review of our series of 70 patients at a single institution who underwent resection of a meningioma involving the dural venous sinuses with reconstruction as needed, evaluating demographics, pre-operative assessment of venous anatomy, surgical technique, and outcomes. ResultsIn our series, we found successful maximal safe resection was achievable in patients with dural venous sinus involvement. We identified no venous infarctions and a low rate of recurrence. ConclusionsMaximal safe resection, including resection and reconstruction of involved sinuses, may be a safe and effective treatment for many patients. Careful pre-operative assessment of venous anatomy and planning extent of resection and reconstruction are essential for safe and successful surgery in these patients.

Effect of Temperature and Salinity on Survival of Protoscoleces of Hydatid Cyst in Liver In Vitro.

Hydatid cyst is the metacestode stage of Echinococcus granulosus that occurs in herbivores and humans as intermediate hosts by consuming parasite eggs through forage and vegetables. Carnivores, as definitive hosts, become infected by consuming infected vesicles of herbivores. The most effective treatment for a hydatid cyst is surgical operation. Inactivating E. granulosus protoscoleces through heating, cooling, or chemicals such as sodium chloride can be considered an effective method for controlling hydatidosis in both humans and animals. The main objective of this study was to evaluate the effect of different temperatures and salinity conditions on the survival of Echinococcus granulosus protoscoleces. For this purpose, 50 g of infected liver (in triplicate) was separately treated with different temperatures (+10°C, +50°C, +60°C, +72°C, and -20°C) and concentrations of sodium chloride (5%, 10%, 15%, and 20%) for 3, 6, 12, 24, 48, and 72 h. Additionally, 50 g of infected liver was stored separately in the refrigerator (+4°C) as a control group. The survival rate of the protoscoleces was evaluated by staining with 1% eosin under a light microscope. The results showed that the protoscoleces were significantly affected, with 100% mortality at -20°C after 0.5 h, and complete death at +72°C, +60°C, +50°C, and +10°C after 1, 1.5, 3, and 24 h, respectively (p < 0.005). Similarly, the protoscoleces in the liver mass survived at 5% NaCl after 3 h but died at 10% after 24 h, at 15% after 12 h, and at 20% after 6 h. It is concluded that exposing the liver infected with protoscoleces hydatid cyst to a temperature of -20°C and a sodium chloride concentration of 10% for 24 h is suitable for inactivating the protoscoleces.

Technique of Colon Interposition for Oesophageal Replacement for Oesophageal Cancer

Nowadays, it is only relatively rare and in selected situations that colonic interposition is chosen rather than the stomach as a reconstructive organ for replacing the oesophagus. The colon is a reliable organ for tubular replacement of the oesophagus when the stomach is not available for reconstruction. Colon interposition is a complex and complicated operation. It requires a specific indication and thorough preoperative preparation. From a technical point of view, colon interposition places high demands on the selection and surgical dissection of the vascular supply to the reconstructed organ. The reconstruction route and elevation of the interposition graft to the proximal oesophagus and the need to create 3 or 4 gastrointestinal anastomoses also place significantly higher demands than reconstruction using a gastric tube. Overall, despite the significant surgery-related morbidity, good functional results and a good quality of life can usually be achieved. The surgical technique applied in our own practice is described in detail. An overview from literature on the results of colonic interposition is given, particularly with regard to surgical complications and quality of life after colon interposition.

Complex intracranial aneurysms: a DELPHI study to define associated characteristics.

Intracranial aneurysms present significant health risks, as their rupture leads to subarachnoid haemorrhage, which in turn has high morbidity and mortality rates. There are several elements affecting the complexity of an intracranial aneurysm. However, criteria for defining a complex intracranial aneurysm (CIA) in open surgery and endovascular treatment could differ, and actually there is no consensus on the definition of a "complex" aneurysm. This DELPHI study aims to assess consensus on variables defining a CIA. An international panel of 50 members, representing various specialties, was recruited to define CIAs through a three-round Delphi process. The panelists participated in surveys with Likert scale responses and open-ended questions. Consensus criteria were established to determine CIA variables, and statistical analysis evaluated consensus and stability. In open surgery, CIAs were defined by fusiform or blister-like shape, dissecting aetiology, giant size (≥ 25mm), broad neck encasing parent arteries, extensive neck surface, wall calcification, intraluminal thrombus, collateral branch from the sac, location (AICA, SCA, basilar), vasospasm context, and planned bypass (EC-IC or IC-IC). For endovascular treatment, CIAs included giant size, very wide neck (dome/neck ratio ≤ 1:1), and collateral branch from the sac. The definition of aneurysm complexity varies by treatment modality. Since elements related to complexity differ between open surgery and endovascular treatment, these consensus criteria of CIAs could even guide in selecting the best treatment approach.

A phase III randomized clinical trial comparing laparoscopic radical hysterectomy based on open state with abdominal radical hysterectomy in patients with early-stage cervical cancer

BackgroundCervical cancer is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women, The standard treatment recommendation for women with early cervical cancer is radical hysterectomy with pelvic lymph node dissection, however, articles published in recent years have concluded that the treatment outcome of laparoscopic surgery for cervical cancer is inferior to that of open surgery. Thus, we choose a surgically new approach; the laparoscopic cervical cancer surgery in the open state is compared with the traditional open cervical cancer surgery, and we hope that patients can still have a good tumor outcome and survival outcome. This trial will investigate the effectiveness of laparoscopic cervical cancer surgery in the open-state treatment of early-stage cervical cancer.Method and designThis will be an open-label, 2-armed, randomized, phase-III single-center trial of comparing laparoscopic radical hysterectomy based on open state with abdominal radical hysterectomy in patients with early-stage cervical cancer. A total of 740 participants will be randomly assigned into 2 treatment arms in a 1:1 ratio. Clinical, laboratory, ultrasound, and radiology data will be collected at baseline, and then at the study assessments and procedures performed at baseline and 1 week, 6 weeks, and 3 months, and follow-up visits begin at 3 months following surgery and continue every 3 months thereafter for the first 2 years and every 6 months until year 4.5. The primary aim is the rate of disease-free survival at 4.5 years. The secondary aims include treatment-related morbidity, costs and cost-effectiveness, patterns of recurrence, quality of life, pelvic floor function, and overall survival.ConclusionsThis prospective trial aims to show the equivalence of the laparoscopic cervical cancer surgery in the open state versus the transabdominal radical hysterectomy approach for patients with early-stage cervical cancer following a 2-phase protocol.Trial registrationChiCTR2300075118. Registered on August 25, 2023.

Macro-réimplantation du membre supérieur : état des lieux en 2024

Macro-amputations are extremely serious traumas and represent one of the rare extreme emergencies in hand and upper limb surgery. Their rarity, especially in our developed countries, makes their treatment relatively unknown by surgical and anesthetic teams. However, the action plan to use during a macro-reimplantation, the decisive elements of pre- and post-operative management, and the key stages of the surgery, must be perfectly known, because they determine the success of a major reimplantation, for the limb survival and the future functional result. After a brief historical overview, the literature review proposed here provides an opportunity for an update on these formidable injuries and propose a treatment algorithm to guide the medical team in the management of these complex patients.

The buccal plug: A technique for management of focal cicatricial entropion and trichiasis.

Cicatricial entropion can be challenging to manage, and surgery may lead to anterior lamellar and focal lash loss or tarsal scarring. We describe a surgical technique to address focal cicatricial entropion that avoids conjunctival incisions and minimizes changes to the aesthetic contour of the eyelid. Four patients underwent surgery with a square portion of the posterior row of eyelash follicles being excised anterior to the tarsus. A buccal mucous membrane graft was then harvested and inserted between the lamella. The plug served to recreate a mucosal membrane at the posterior reflection of the eyelid and separate the anterior and posterior lamella mechanically. With a mean follow-up of 5.16 months, no patients experienced regrowth of lashes at the graft site, and corneal irritation from aberrant eyelashes was abated. The buccal plug technique provides an aesthetically minded, less invasive approach to surgical management of localized entropion with trichiasis.

"Inverted flap rhexis" - Salvation of intumescence.

Intumescent cataract can be a challenge even for an experienced surgeon, particularly for creating a continuous curvilinear capsulorhexis (CCC) because of increased endolenticular pressure. CCC in white intumescent cataract is associated with increased risk of extension of rhexis margin leading to radial tear or biradial extension causing "Argentinian flag sign" and associated complications. We describe a novel technique for CCC, in which we manipulate the vector forces acting in creating a capsulorhexis. After making a mini CCC, a flap is raised and then inverted under the rhexis margin and CCC is done by keeping the flap inverted using shearing and tearing forces, keeping the direction of force down and toward the center in a curvilinear fashion. It is a new surgical technique to perform a successful and safer CCC in intumescent cataract with consistent outcome.

A Prospective Quality Improvement Program to Reduce Prolonged Postoperative Antibiotic Prophylaxis in Ethiopia.

Introduction: Although postoperative antibiotic prophylaxis has not been shown to prevent surgical site infections, prolonged antibiotic administration is common in low- and middle-income countries. We developed a quality improvement program to reduce unnecessary postoperative antibiotics through hospital-specific guideline development and the use of a brief, multidisciplinary discussion of antibiotic indication, choice, and duration during clinical rounds. We assessed reduction in the number of patients receiving ≥24 h of antibiotic prophylaxis after clean and clean-contaminated surgery. Methods: We piloted the program at a referral hospital in Ethiopia from February to September 2023. After a 6-week baseline assessment, multidisciplinary teams adapted international guidelines for surgical prophylaxis to local disease burden, medication availability, and cost restrictions; stakeholders from surgical departments provided feedback. Surgical teams implemented a "timeout" during rounds to apply these guidelines to patient care; compliance with the timeout and antibiotic administration was assessed throughout the study period. Results: We collected data from 636 patients; 159 (25%) in the baseline period and 477 (75%) in the intervention period. The percentage of patients receiving ≥24 h of antibiotic prophylaxis after surgery decreased from 50.9% in the baseline period to 40.9% in the intervention period (p = 0.027) and was associated with a 0.5 day reduction in postoperative length of stay (p = 0.047). Discussion: This antibiotic stewardship pilot program reduced postoperative antibiotic prophylaxis in a resource-constrained setting in Sub-Saharan Africa and was associated with shorter length of stay. This program has the potential to reduce unnecessary antibiotic use in this population.