Operative Technical Details Research Articles

Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network

Although hypospadias outcomes studies typically report a level or type of repair performed, these studies often lack applicability to each surgical practice due to technical variability that is not fully delineated. An example is the tubularized incised plate (TIP) urethroplasty procedure, for which modifications have been associated with significantly decreased complication rates in single center series. However, many studies fail to report specificity in techniques utilized, thereby limiting comparison between series. With the goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) current techniques used by surgeons in our network for recording operative notes and 2) operative technical details by surgeon for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network. A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each was analyzed by at least two individuals for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice techniques and instrumentation. Twenty-five surgeons from 12 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed. In 7 proximal and 14 distal repairs, parameters for chordee correction, urethroplasty suture selection and technique, tissue utilized, and catheter selection varied widely across surgeons. Wide variability in technical surgical details of categorically similar hypospadias repairs was demonstrated across a large surgical network. Surgeon-specific modifications of commonly described procedures are common, and further evaluation of short- and long-term outcomes accounting for these technical variations is needed to determine their relative influence.

Propeller Flaps.

A propeller flap is an islanded flap that reaches the recipient site through an axial rotation around its vascular axis. The degree of rotation varies from 90 degrees to 180 degrees. It is a highly reliable local reconstructive option. These flaps are simple, single-stage, easy to harvest, and not constrained by routine length-to-width ratios. Since their introduction, the technique has continued to evolve and more applications for the use of propeller flaps are being explored. In spite of their growing use in clinical practice in recent years, many reconstructive surgeons are unaware of their versatility, unsure of their safety, and apprehensive about using propeller flaps confidently. This article aims at understanding the nomenclature, key principles, biogeometry and planning, operative technical details, applications, and complications of propeller flaps.

Does Ventral Rectopexy Improve Pelvic Floor Function in the Long Term?

Information is needed on long-term functional results, sequelas, and outcome predictors for laparoscopic ventral mesh rectopexy. The purpose of this study was to evaluate long-term function postventral rectopexy in patients with external rectal prolapse or internal rectal prolapse in a large cohort and to identify the possible effects of patient-related factors and operative technical details on patient-reported outcomes. This was a retrospective review with a cross-sectional questionnaire study. Data were collated from prospectively collected registries in 2 university and 2 central hospitals in Finland. All 508 consecutive patients treated with ventral rectopexy for external rectal prolapse or symptomatic internal rectal prolapse in 2005 to 2013 were included. A questionnaire concerning disease-related symptoms and effect on quality of life was used. Defecatory function measured by the Wexner score, the obstructive defecation score, and subjective symptom and quality-of-life evaluation using the visual analog scale were included. The effects of patient-related factors and operative technical details were assessed using multivariate analysis. The questionnaire response rate was 70.7% (330/467 living patients) with a median follow-up time of 44 months. The mean Wexner scores were 7.0 (SD = 6.1) and 6.9 (SD = 5.6), and the mean obstructive defecation scores were 9.7 (SD = 7.6) and 12.3 (SD = 8.0) for patients presenting with external rectal prolapse and internal rectal prolapse. Subjective symptom relief was experienced by 76% and reported more often by patients with external rectal prolapse than with internal rectal prolapse (86% vs 68%; p < 0.001). Complications occurred in 11.4% of patients, and the recurrence rate for rectal prolapse was 7.1%. This study was limited by its lack of preoperative functional data and suboptimal questionnaire response rate. Ventral mesh rectopexy effectively treats posterior pelvic floor dysfunction with a low complication rate and an acceptable recurrence rate. Patients with external rectal prolapse benefit more from the operation than those with symptomatic internal rectal prolapse. See Video Abstract at http://links.lww.com/DCR/A479.

102 lumbar pedicle subtraction osteotomies: one surgeon's learning curve.

Pedicle Subtraction Osteotomy (PSO) is an effective surgical technique for the correction of fixed sagittal malalignment of the spine. It is a demanding technique that requires a long learning curve. The aim of this study is to analyze a surgeon's learning curve for lumbar PSO in relation to the preoperative, perioperative, and postoperative management, with assessment of the global outcome. 102 patients operated over an 8-year period were included, distributed in 3 groups over the time, and retrospectively analyzed. The following data were collected: demographic characteristics, preoperative and postoperative radiological parameters, operative technical details, and complications. Multiple regression analysis was performed, and while the number of cases was the predictor, other variables such as demographic, radiographical, and surgical variables were considered as a covariate in the final model. When comparing the first group and the last group of patients, the mean surgical time had decreased by 50min, the estimated blood loss was decreased by 655ml, and a significant decrease in dural tear occurrence was noticed. In addition, we found a significant decrease in the hospital stay length. Multivariate linear regression analysis showed that when the surgeon's experience doubles, the operative time decreases by 29min, the blood loss by 281ml, and the odds of hospital stay≥21days decrease by 0.66 times. PSO technique has a relatively long learning curve. This study showed that accumulating the experience over the years, while performing cases on a regular basis, is definitely the key in mastering this complex and risky technique, with significant improvements in the perioperative parameters that directly impact the recovery and global outcome. These slides can be retrieved under Electronic Supplementary Material.

Blood loss and transfusion rates in DIEP flap breast reconstruction. Introducing a new predictor

The popularity of the DIEP flap has increased over the last decade. However, there is little information regarding the transfusion rates of this complex procedure. The current study reports the transfusion rates in patients who underwent DIEP flap reconstruction in our unit with an attempt to correlate significant blood loss with potential predictors such as the abdominal flap weight. A retrospective review of 131 patients who underwent DIEP reconstruction was performed. Patients' characteristics, risk factors, incidence of blood transfusions, Hb drop and complications were reviewed. For statistical analysis the two-tailed Student t-test, chi-squared significance test and multiple regression model were used. 12 patients (9.1%) were transfused compared to 80.3% and 18.8% described in the literature. Definite association was found between the presence of a complication and transfusion. No correlation was found between age, obesity, chemotherapy and/or radiotherapy or tamoxifen treatment and blood loss. However, operation duration, complications and weight all found to have significant correlation. On average, every additional hour of surgery adds 0.25g of Hb drop; the presence of a complication adds 0.45g of Hb drop, and every extra gram of tissue removed from the abdomen adds an extra 0.001g of Hb drop. The different transfusion rates published reflect variations in surgical strategies, different operative technical details but mostly transfusion protocols applied in each unit. As a correlation with complications was found, it is quite important to identify predictors for significant blood loss to optimise the operation outcome which in our study are additional time of surgery, the presence of complication and increased flap weight.

Endoscopic Orbital Decompression: When and How?

Objective: 1) Identify acute and chronic indications for orbital and/or optic nerve decompression. 2) Review known techniques for endoscopic orbital decompression. 3) Evaluate the necessity to include inferior orbital wall/orbital floor. 4) Compare and contrast the endoscopic technique in comparison to various open methods. Method: Retrospective review of all patients that underwent endoscopic orbital decompression procedures between 2009 and 2011. Data analysis included review of perioperative clinical findings, operative technical details, radiology data, and outcomes. Results: A total of 15 orbital decompressions were performed. All patients underwent endoscopic medial orbital wall decompression, 2 included the orbital floor. The majority of the patients had allergic fungal sinusitis as their primary diagnosis for surgical indication (n = 7, 47%). Neoplasms (n = 5, 33%) and Graves disease (n = 3, 20%) were the remaining diagnoses. Restricted ocular motility, proptosis, and diplopia were the most common presentations indicating surgery (n = 13, 11 and 8, respectively). Resolution of diplopia was observed in all patients, but delayed in Graves patients (2-3 months). Proptosis improved in 7 patients (64%), without any significant difference among those including orbital floor. Conclusion: The endoscopic technique for orbital decompression is a safe and less invasive alternative to currently used open approaches. Sufficient medial wall decompression may yield sufficient outcomes, precluding the need for including the orbital floor. Further objective outcomes data is needed to compare proptosis among various modes of endoscopic decompression techniques.

Clinical Experience of Endoleak after Endovascular Aortic Aneurysm Repair

Purpose: Endoleak is a common complication following endovascular aortic aneurysm repairs (EVAR). The aim of this study was to discover the frequency and characteristics after EVAR with on-label use. Methods: A retrospective review was performed on 25 patients who underwent EVAR in Inha University Hospital between December 2005 and February 2009. The data included in this study accounted for patient characteristics, anatomic features, operative technical details, and types of devices used. The results of EVAR were analyzed for clinical success, technical success and endoleak. Results: Endoleaks were observed during 11 (47.8%) procedures. Type Ⅰ endoleaks were observed in 2 (18.2%) cases. A total of 6 type Ⅱ intraoperative endoleaks (54.5%) were observed. 3 type Ⅲ endoleaks (27.3%) occurred. But all endoleaks were resolved without additional intervention CT scan after 6 months. Conclusion: Although the endovascular management of AAAs is less invasive than open surgery, many complications including endoleak were still the most common adverse event during the first postoperative month. However, observation may be a good treatment for minor endoleak after EVAR.

Fracture-related Thoracic Kyphotic Deformity Correction by Single-stage Posterolateral Vertebrectomy With Circumferential Reconstruction and Stabilization

This paper is a retrospective chart review. This study assesses single-stage thoracic vertebrectomy with circumferential reconstruction and stabilization. Preoperative and postoperative thoracic kyphotic angles and other outcomes are analyzed. Pathologic and traumatic thoracic vertebral body fracture deformity can be corrected by an anterior vertebral body corpectomy and reconstruction. If the pathology is primarily posterior, then laminectomy and posterolateral instrumentation may be preferred. In some patients, simultaneous anterior and posterior correction of instability and fracture is necessary and is now possible with a single-stage Stanford University Medical Center (SUMC) technique with similar results to the traditional 2-stage approach. Thirty patients who underwent 31 single-stage thoracic vertebrectomies with circumferential reconstructions for thoracic spine fractures between 2004 and 2006 at SUMC were retrospectively reviewed. All surgeries were performed prone; operative technical details are reported. The preoperative and postoperative thoracic kyphotic angles were measured by Cobb angle evaluation using lateral chest plain films and magnetic resonance imaging. Other outcome measures evaluated included operative time, blood loss, neurologic and functional outcomes, postoperative pain, and treatment complications. The mean follow-up was 17.21 months (range: 9 to 30 mo) and preoperative kyphosis was 20.4 degrees (range: 6.0 to 57.9 degrees). The average postoperative kyphosis was 8.3 degrees (range: 1.8 to 2.67 degrees) and correction of kyphosis was 16.2 degrees (range: 6 to 30 degrees). The median estimated blood loss was 1411.67 mL (range: 300 to 4000 mL) and mean operating time was 4.8 hours (range: 2.8 to 8.6 h). Complications included 2 hardware failures requiring revision, 2 infections, and 1 dural laceration. Pain, Frankel Grade, and functional status were improved in all, except 1 preoperatively bedridden patient. Thoracic kyphotic correction is possible through a prone single-stage simultaneous anterior vertebrectomy and posterior reconstruction. Sufficient anterior and posterior correction of instability and fracture using the SUMC technique is possible with similar results to the traditional 2-stage approach.

Trigeminal nucleus caudalis dorsal root entry zone radiofrequency thermocoagulation for invalidating facial pain

Facial pain syndromes occasionally result in desperate clinical settings completely unresponsive to any known therapy. Trigeminal nucleus caudalis dorsal root entry zone (DREZ) lesion is reported to be of benefit in such cases. In 1982 Nashold performed the first DREZ caudalis lesion in a patient with anaesthesia dolorosa. From 1994 to 2002 we have performed six DREZ caudalis lesions on five patients with extremely invalidating facial pain resistant to multiple pharmacological and surgical therapies. Pain was secondary to previous craniofacial surgery in all but one case. Pain presented as anaesthesia dolorosa or atypical facial pain so severe as to interfere with personal hygiene and even to prevent patients from oral feeding. A midline suboccipital approach was used and radiofrequency lesions (at the trigeminal nucleus caudalis in the cervicomedullary junction) were made at 1-mm intervals, 75 (o)C for 15 seconds each along the ipsilateral posterolateral sulcus from the cervical DREZ up to the obex. Pain relief was complete and permanent in two patients. Three patients experienced significant improvement but pain recurred in two (weeks to a few months after the procedure). No patient's pain was made worse. A patient with persistent postoperative nasolabial pain was re-operated on (improving again but ultimately remaining unchanged). Air venous embolism related to the sitting position (3 patients) during surgery and bradycardia due to manipulation in medulla (2 patients) occurred during some of the procedures without any cardiovascular or neurological repercussion. Postoperative complications included mild and transient ataxia and monoparesia (3 patients). Facial pain secondary to craniofacial surgery is known to be among the least responsive to treatment and a true challenge for pain clinicians. Actual indications for this procedure, operative technical details and the results of our series compared to previous reports are reviewed. Trigeminal nucleus caudalis radiofrequency thermocoagulation is an effective neurosurgical procedure for the treatment of chronically debilitating and desperate facial pain syndromes with acceptable morbidity.

The evolving technique of endovascular stenting of abdominal aortic aneurysm; time for reappraisal.

to investigate the occurrence of intra-operative device-related complications during stent-grafting for abdominal aortic aneurysm. data on patient characteristics, vascular morphology, operative technical details, procedural and device-related complications were obtained from the European collaborators on stent-graft techniques for abdominal aortic aneurysm repair (EUROSTAR) registry. Only intra-operative device-related complications were taken into account. Potential risk factors for device-related complications were examined by logistic regression analysis. The association between these complications and conversion to open surgery and death were determined. between January 1994 and July 2000, 2862 patients in 90 participating hospitals underwent endovascular abdominal aortic aneurysm repair. Device-related complications occurred in 238 (8.3%) patients. Complications were associated with the age of the patient (p=0.002), gender (p=0.05), smoking habit (p=0.001), pre-operative aneurysm diameter (p=0.005), type of device implanted (p=0.0001), fitness of the patient for open surgery (p=0.002), and year of operation (p=0.001). Adjusted for risk factors, the occurrence of complications decreased between 1994 to 2000 from 21.7% to 7.3%, respectively. Patients with device-related complications were 13.6 times (95% CI; 9.2-20.1) more likely to have conversion to an open procedure and 2.4 times (95% CI; 1.4-4.0) more likely to die within 30 days of the operation. intra-operative device-related complications were common, although appear to be decreasing in frequency, and were significantly related to conversion and post-operative death.

Early complications and endoleaks after endovascular abdominal aortic aneurysm repair: Report of a multicenter study

Objective: The aim of this study was the identification of risk factors for adverse events and the assessment of the early success rate in 1554 patients with abdominal aortic aneurysms (AAAs) who underwent treatment with endovascular technique between January 1994 and March 1999. For this purpose, the clinical and procedural data were correlated with observed complications and endoleaks. Methods: The data were collected from 56 European centers and submitted to a central registry. Patient characteristics, aortoiliac anatomic features, operative technical details, types of devices used, and experience of the teams of physicians were correlated with the occurrence of complications and endoleaks. The technical success rate was assessed according to the Society for Vascular Surgery/International Society for Cardiovascular Surgery, North American Chapter, guidelines. For the assessment of correlations between risk factors and adverse events, a multivariate logistic regression analysis was used. Results: The operative complications were grouped into three categories: failure to complete the procedure (39 patients, of which 27 underwent a conversion to an open AAA repair; 2.5%); device-related or procedure-related complications (149 patients; 10%); and arterial complications (51 patients; 3%). The most important risk factors for failure to complete the procedure included an aneurysm diameter of 60 mm or more and the need for adjuvant procedures. The factors that predicted device-related and arterial complications were the experience of the team with endovascular AAA treatment and the need for adjuvant procedures. Forty patients (2.6%) died within 30 days after operation. American Society of Anesthesiologists III and IV operative risk classification results predicted higher mortality rates than did American Society of Anesthesiologists operative risk classification I and II results. The patients who underwent operation in 1994, the first year documented in this registry, and those who required adjuvant procedures also had an increased risk of perioperative death. The incidence rate of systemic complications within the first 30 days (279 patients; 18%) was higher in patients aged 75 years or more, in patients with an impaired cardiac status, and in patients considered unfit for an open procedure. An endoleak was detected at the completion of the procedure in 16% of the cases and was still present after 1 month in 9%. The risk factors for primary endoleaks were female gender and age of 75 years and older. The observed technical success rate in this patient series was 72%. Conclusion: The learning curve of the doctors and the need for adjuvant procedures were independent risk factors of operative device-related and arterial complications. The importance of proper instruction during an institution's initial phase with this treatment is emphasized by these observations. Although the endovascular management of AAAs is less stressful than open surgery, systemic complications were still the most common adverse events during the first postoperative month. These complications were associated with several patient-related factors, including advanced age, impaired cardiac status, and poor general medical condition. These observations may be a guide for improved patient selection for endovascular AAA repair. (J Vasc Surg 2000;31:134-46.)

Our ames is true: How an old concept still hits the mark: or, risk group assignment points the arrow to rational therapy selection in differentiated thyroid cancer

Our ames is true: How an old concept still hits the mark: or, risk group assignment points the arrow to rational therapy selection in differentiated thyroid cancer

Proceedings: Aortoenteric and paraprosthetic-enteric fistulas. Problems of diagnosis and management.

The clinical characteristics, surgical treatment, and therapeutic results were surveyed in 11 cases of aortoenteric and 8 cases of paraprosthetic-enteric fistulas observed in 2,085 abdominal aortic reconstructive operations. The clinical manifestations of these lesions were exsanguinating hemorrhage or medically uncontrollable retroperitoneal sepsis. The diagnosis of aortoenteric or paraprosthetic-enteric fistulization must be assumed in every case of abdominal aortic reconstruction with late hemorrhagic or septic complications. The treatment is early and aggressive surgical intervention supported with appropriate antibiotic medication. Some operative technical details appear useful in reducing the probability of occurrence of these complications.