Optimal Surgical Technique Research Articles

Arthroscopy Is at Least as Effective as Arthrotomy for Treatment of Septic Arthritis in Adults: A Systematic Review of Large and Intermediate Joints.

Surgical options for septic arthritis include open arthrotomy or an arthroscopic procedure. The optimal surgical technique remains a matter of debate as acceptable results have been reported for both. To evaluate the efficacy of arthroscopy versus arthrotomy for the treatment of septic arthritis in large and intermediate-sized joints. Systematic review; Level of evidence, 3. A literature search was performed of the PubMed and Cochrane online databases through September 2023 identifying articles comparing arthroscopy with arthrotomy for the treatment of septic arthritis. Eligible articles included retrospective or prospective comparative studies investigating reoperation, perioperative complications, or clinical outcomes after arthroscopic or open treatment for septic arthritis of the shoulder, elbow, wrist, hip, knee, or ankle in adults. In total, 23 articles with 34,248 patients met the inclusion criteria comparing arthroscopy with arthrotomy. In 14 of the 20 (70%) studies that reported on reoperation rates, there was no significant difference in arthroscopic versus open surgical management for septic arthritis. Four (20%) studies reported lower reoperation rates when arthroscopy was utilized compared with open arthrotomy. One single-institution study found arthrotomy to be more effective for shoulder septic arthritis, and another favored open surgery only in the presence of erosions. In 11 of 23 (47.8%) studies, no difference in complications or clinical outcomes was found. However, 11 of 23 (47.8%) studies comprising the shoulder, wrist, hip, knee, and ankle reported a significant benefit to arthroscopy for improved outcomes. Arthroscopic surgery for the treatment of septic arthritis involving the shoulder, wrist, hip, knee, and ankle appears to be safe and effective. Reoperation rates, short-term complications, and functional outcomes tend to be similar or in favor of arthroscopy when compared with arthrotomy.

Evaluating Failure Rates of Primary Quadriceps Tendon Repairs Across Different Surgical Techniques.

Quadriceps tendon ruptures occur infrequently in the general population. Biomechanical data suggest advantages with the use of suture anchor fixation for major tendon repair. Clinical studies of quadriceps tendon repair have been limited to small case series. To evaluate clinical failure following primary quadriceps tendon repair with transosseous tunnel or suture anchor repair. Cohort study; Level of evidence, 3. The Military Health System Data Repository was queried to identify all adult patients who underwent primary quadriceps tendon repair in the Military Health System between 2014 and 2018. Patients were excluded if they had incomplete records, polytrauma, open injury, prior ipsilateral total knee arthroplasty did not undergo quadriceps tendon repair, or underwent revision repair. Follow-up was obtained by manual chart review of both orthopaedic and nonorthopaedic records, recording any evidence of ongoing knee issues. Univariate analysis was performed to determine associations between potential risk factors and repair failure. Multicollinearity was assessed between potential risk factors, and candidate variables were included in multivariate logistic regression models to determine independent risk factors for repair failure. Following application of inclusion/exclusion criteria, 245 knees in 234 patients were included. Mean age of the cohort was 52 years. Patients were predominantly male (223/234; 95%) and military retirees (143/234; 61%). Transosseous tunnel repair was the most frequently employed surgical technique (147/245; 60%), followed by suture anchor repair (78/245; 32%). Repair failure requiring revision surgery occurred in 11% of knees (27/245). Surgical-site infection following index surgery was associated with eventual rerupture (P = .02). There was no difference in failure rate between transosseous tunnel repair and suture anchor repair (12.2% vs 9.0%; P = .51). Among knees undergoing suture anchor repair, no difference in failure was found between knot-tying and knotless suture anchor fixation (P = .73). We observed no difference in failure of primary quadriceps tendon repair between transosseous tunnel and suture anchor repair types or between the 2 main suture anchor implant subtypes (knotless vs knot-tying anchors). A greater than previously reported rerupture rate was observed, indicating the need for continued investigation into optimal surgical techniques.

Transposition of the Great Arteries with Intramural Left Main Coronary Artery—Salient Imaging Findings and Choice of Operative Technique

D-transposition of the great arteries (D-TGA) is a common cyanotic critical congenital heart disease. An arterial switch operation (ASO) with/without a ventricular septal defect (VSD) closure is the preferred surgical approach, with an added challenge when an intramural coronary artery (IMC) is present (1), with a reported increased incidence of postoperative complications and mortality (2,3). We present our recent D-TGA with intramural coronary artery (TGA-IMC) experience, focusing on the salient features identified on echocardiography, computed tomography (CT) angiography, and invasive angiograms, as well as variations in ASO surgical techniques for repair. Diagnostic imaging evaluation allowed for identification of the lesion, as well as planning for and undertaking of two different surgical approaches. While the two patients had differing immediate postoperative courses, both were asymptomatic at discharge, with normal biventricular systolic function. Our experience demonstrates that the suspicion for a coronary anomaly in TGA can be raised prenatally and confirmed postnatally with focused trans-thoracic echocardiography and ECG-gated CT angiogram evaluation while also aiding in operative planning. Moreover, suggesting further exploration of the optimal surgical technique for the repair of TGA-IMC.

Opinions of Gynecologists About Indication and Technique of Perineoplasty

Background. Perineoplasty is a frequently performed procedure as part of prolapse surgery. Despite its frequent use, there is a lack of evidence on the optimal indication, surgical technique and adverse outcomes. We intended to gain insight into the current opinions on indications and techniques of perineoplasty among (uro)gynecologists worldwide. Methods. We conducted a survey among members of the International UroGynecological Association (IUGA) to objectify indications for perineoplasty and aspects of surgical technique. Results. A total of 114 urogynecologists responded, with 98% performing perineoplasty. A total of 85% of respondents aimed to approximate the bulbocavernosus muscle, whereas 27% aimed to include the puborectal muscle as well. A total of 86% of respondents used 1–4 resorbable sutures, especially vicryl 2/0 (39%) or vicryl 0 (52%). According to the respondents, a “wide genital hiatus at physical examination” (87%) and “subjective complaints of a wide genital hiatus” (84%) were considered good/excellent indications for perineoplasty, whereas “fecal incontinence”, “apical prolapse” and “perineal pain” were absolutely/mostly not a good indication. Reasons to not perform perineoplasty were pelvic pain (59%) and dyspareunia (64%). Most responders underlined the need for more research on this topic (8.5 out of 10). Conclusions. Perineoplasty is a frequently performed procedure. There is a wide variation in the indications for and surgical techniques of perineoplasty. Therefore, research is needed to identify which patients will benefit from perineoplasty and how to optimally perform this surgery.

Aesthetic and Functional Outcomes of Simultaneous Rhinoplasty and Lip Lift Surgery: A Systematic Review.

Rhinoplasty and lip lift surgeries are pivotal procedures in facial aesthetics, addressing nose and lip enhancements, respectively. The concurrent execution of these surgeries has gained popularity for achieving improved facial balance and harmony. However, data on the outcomes of combined rhinoplasty and lip lift procedures remain limited. This study aims to evaluate the aesthetic outcomes, complications, and patient satisfaction of simultaneous rhinoplasty and lip lift surgeries. This systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search across PubMed, Scopus, Medline, Science Direct, and Web of Science was performed, focusing on studies reporting simultaneous rhinoplasty and lip lift surgeries. The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias in the included studies. Data on aesthetic outcomes, complications, and patient satisfaction were extracted and synthesized. A total of six studies, encompassing 361 patients, were included. Results demonstrated high patient satisfaction, with favorable aesthetic outcomes such as improved nasolabial and frontonasal angles and shortened lip length. Minimal complications were reported, with mild scarring and temporary paraesthesia being the most common, both resolving within a few months. Functional outcomes were positive, with no long-term impairments in nasal airflow or lip function. Simultaneous rhinoplasty and lip lift surgeries yield high patient satisfaction and excellent aesthetic outcomes with minimal complications. The findings suggest this combined approach is safe and effective, particularly for patients seeking enhanced facial harmony. Future studies should focus on long-term outcomes and the optimization of surgical techniques.

Radiographic and Clinical Outcomes of First Tarsometatarsal Joint Arthrodesis With a Biplanar Locking Plate System Versus the Modified Lapidus Technique With Crossed-Screw Fixation: A Retrospective Multicenter Comparison.

Background: Hallux valgus (HV) is recognized as a triplanar deformity. A biplanar locking plate (BLP) system corrects this deformity through first tarsometatarsal joint (TMTJ) arthrodesis, with specialized reduction tools and cutting guides. Yet the optimal surgical technique and fixation construct for first TMTJ arthrodesis remains controversial. Purpose: We sought to compare the BLP system with a modified Lapidus (ML) technique with crossed-screw fixation in terms of radiographic outcomes, complications, and reoperations. Methods: In this retrospective multicenter study, we identified a series of consecutive patients who underwent first TMTJ arthrodesis for HV with either the ML procedure at institution A or the BLP system at institution B. Patients 18 years of age with a minimum of 6 months of postoperative radiographs were included. There were 130 patients, 65 in each group, including 121 women (93.8%) with a median age of 58 years and mean radiographic follow-up of 7.1 months. Data included preoperative and postoperative HV angle (HVA), intermetatarsal angle (IMA), and tibial sesamoid position (TSP), plus complications and reoperations. Statistical testing included Mann-Whitney U, Wilcoxon signed rank, Fisher exact, McNemar, and multivariable regression. Results: After adjusting for confounding variables, the BLP system was associated with significantly greater improvements in postoperative IMA and HVA but not TSP. There were no significant differences in rates of complications (ML: 18.4%; BLP: 9.2%) or reoperations (ML: 4.6%; BLP: 7.7%). Conclusion: This retrospective multicenter review found that the BLP system was associated with greater improvement in radiographic HV parameters compared with the ML procedure using crossed-screw fixation. Clinical significance is unclear as complication and reoperation rates were similar between groups. Further study in this regard is warranted.

Addressing meniscal deficiency part 1: An umbrella review of systematic reviews and meta‐analyses on meniscal allograft transplantation

AbstractPurposeMeniscal injuries are common in the young and active population. There is increasing utilization of surgical interventions like meniscal allograft transplantation (MAT) to restore the protective function of menisci following injury leading to meniscal deficiency. Extensive research and publications exist on the management of meniscal injury and the sequalae of meniscal deficiency. However, a comprehensive synthesis of the existing evidence through an umbrella review is lacking. This study aims to fill this gap by providing a current examination of the literature on MAT.MethodsA comprehensive search was conducted in the MEDLINE, Embase and Scopus databases to identify relevant systematic reviews and meta‐analyses. Studies were screened based on predefined inclusion and exclusion criteria. The quality of the included studies was assessed using the AMSTAR‐2 tool.ResultsA total of 41 studies were included in the review, with most published within the last decade. The majority of studies (56.1%) received a ‘Critically Low’ confidence rating, 26.8% were rated as ‘Low’, and only 14.6% were rated as ‘High’ confidence. From the included studies, 51.2% reported on PROMs, with the Lysholm score being the most common. Transplant failure and reoperation rate were reported in 34.1% and 19.5% of studies respectively. Studies on MAT reported favourable short‐term outcomes in terms of patient‐reported outcome measures (PROMs) but were limited by the lack of randomized control trials and consistent comparison groups.ConclusionsThis umbrella review highlights an increase in interest in MAT but underscores the need for higher‐quality reviews with standardized reporting and rigorous methodologies. Future research should focus on long‐term outcomes, optimal surgical techniques, patient selection criteria and risk factors for transplant failure. There is also a need for more studies focusing on MAT in pediatric populations. Overall, this review provides a comprehensive assessment of the current state of research in MAT and identifies areas for improvement in future studies.Level of EvidenceLevel IV.

Impact of Surgical Technique on Reducing the Incidence of Postoperative Pancreatic Fistula: A Systematic Review and Meta-Analysis

<i>Background</i>: Postoperative pancreatic fistula (POPF), a complication frequently encountered following pancreaticoduodenectomy. Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the most frequently utilized reconstructive strategies with different anastomosis techniques. This study was conducted to evaluate the optimal surgical technique to prevent POPF. <i>Methods</i>: The study was conducted using PRISMA guidelines with PROSPERO registration No. CRD42023494393. Patients undergoing pancreaticoduodenectomy includes the use of PJ or PG with different anastomoses techniques and developed POPF were included. We conducted a systematic literature review from January 2019 to December 2023 using a comprehensive search strategy, through Web of Science, ProQuest, Science Direct, PubMed, and Google Scholar databases. Meta-analysis was utilized to analyze the outcomes. The risk of bias was assessed using the Newcastle-Ottawa scale. <i>Results</i>: Eighteen studies with 3343 patients who underwent various anastomoses (including the Modified DuVal, Heidelberg PJ, and Blumgart methods) were included. Postoperative pancreatic fistula (POPF) occurred in 27% of patients. Techniques such as modified Heidelberg, Peng, shark mouth PJ, and Kiguchi PJ were associated with lower POPF rates, whereas modified and classical Blumgart techniques exhibited higher rates. While mortality rates varied among surgical techniques, overall mortality was low. <i>Conclusions</i>: Data from this study can be used to shape future studies and direct physicians to develop strategies to reduce the risk of POPF and thereby reduce morbidity and mortality, leading to improved patient outcomes. Furthermore, this data can inform clinical decision-making and guide the development of evidence-based practice guidelines to optimize surgical outcomes.

Pooperacinių išvaržų gydymo naudojant tinklelį atokieji (daugiau negu penkerių metų) rezultatai: literatūros apžvalga

Introduction. Postoperative hernias occur in 10–15% of patients. Considering the increase in the incidence of complications with the number of operations it is crucial to choose the optimal surgical technique in order to control the complications rate. This literature review summarizes previous studies on the treatment of postoperative hernias with mesh, comparing complication and recurrence rates according to surgical technique and mesh position. Methods. A thorough search was conducted on the PubMed database to retrieve literature on recurrence, chronic pain, haematoma, seroma, and surgical site infections rates. The results were meticulously summarised and used to confidently compare open and laparoscopic surgical techniques, as well as “sublay” and “onlay/inlay” mesh positions in more than 5-year follow-up. Results. The analysis was conducted on five publications that met the selection criteria. The results showed that laparoscopically treated hernias had lower recurrence and chronic pain rates, but more frequent haematomas. The presence of wound infections, BMI >30, treatment of recurrent postoperative hernias, multiple fascia lesions, enterotomy, larger abdominal wall defect and longer operative time were observed to be associated with higher recurrence rates. The position of the sublay mesh is associated with less frequent seromas, surgical infections, and recurrence compared to the onlay/inlay position. Studies have reported the superiority of large-pore lightweight polypropylene multifilament mesh over the same heavyweight mesh in managing postoperative hernias. Lightweight mesh is linked to a lower risk of hernia recurrence and higher compliance with the abdominal wall. Conclusion. Laparoscopic surgery is associated with lower rates of recurrence and chronic pain, but a higher frequency of haematomas. The sublay mesh position is associated with lower rates of seromas, surgical infections, and recurrence.

Safe and beneficial outcomes of pancreaticogastrostomy with endoscopic transgastric drainage for pancreatic fistula after pancreaticoduodenectomy

PurposesThe optimal surgical technique and perioperative management to prevent postoperative pancreatic fistula (POPF) formation after pancreaticoduodenectomy have not yet been established. This study examined the perioperative outcomes of pancreaticogastrostomy with endoscopic transgastric drainage. MethodsWe performed a retrospective analysis of 191 patients who underwent pancreaticoduodenectomy between 2016 and 2023. They were divided into two groups: pancreaticojejunostomy group (n = 135) and pancreaticogastrostomy group (n = 56). We compared preoperative factors and postoperative outcomes. We performed endoscopic drainage only in the pancreaticogastrostomy group. ResultsPreoperative factors were similar between the two groups. Operative time [480 (404–542) vs. 382 (346–458) minutes], blood loss [505 (270–850) vs. 315 (145–535) g], pseudoaneurysm formation (7 % vs. 0 %), and postoperative hospital stay [28 (22–38) vs. 19 (17–24) days] were significantly lower in the pancreaticogastrostomy group. In the analysis of 41 patients with POPF, postoperative hospital stay [40 (23–108) vs. 27 (18–54) days] and hospital stay after POPF diagnosis [30 (10–99) vs. 15 (5–35) days] were significantly shorter in the pancreaticogastrostomy group. Endoscopic transgastric drainage was performed in 77 % of patients in the pancreaticogastrostomy group, and drainage was successfully completed in all patients. ConclusionPancreaticogastrostomy with endoscopic transgastric drainage could be effective for the safe management of pancreaticoduodenectomy.

Dunking Pancreaticojejunostomy With Braun's Jejunojejunostomy: Perioperative Outcomes of a Hundred Pancreaticoduodenectomies.

Background The optimal surgical technique for pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD) is still debated. Dunking and duct-to-mucosa PJ are the most commonly adopted techniques. Incorporating Braun's jejunojejunostomy (JJ) could reducetheincidence and severity of delayed gastric emptying (DGE). This retrospective descriptive study seeks to clarify the outcomes of dunking PJ with Braun's JJ in 100 PD patients. Methodology We retrospectively reviewed 100 patients who underwent PDs in a single unit of the Department of Surgical Gastroenterology of Tribhuvan University Teaching Hospital from October 2012 to February 2023. Demographic and historical data, indications, procedure-related data, complications, and mortality data were collected and analyzed. Results The mean age was 50.96 ± 14.97 years, and 64 (64%) were males. The most common indication was ampullary carcinoma (53, 53%) followed by distal cholangiocarcinoma (18, 18%) and pancreatic ductal adenocarcinoma (7, 7%). Operative time was 5.83 ± 1.09 hours, intraoperative blood loss was 515 ± 194 mL, and the average time for PJ and Braun's JJ was 22 ± 6 and 15 ± 3 minutes, respectively. Soft pancreas was encountered in 52 (52%) patients and clinically significant postoperative pancreatic fistula (Grade B, C) was seen in 23 (23%). Postpancreatectomy hemorrhage was seen in 21 (21%) patients (Grades A: 3, B: 12, C: 6). DGE (Grade B) occurred in two (2%) patients, and bile leak was observed in 4% of patients (Grades A: 1, B: 2, C: 1). Major complications (Clavien-Dindo ≥IIIA) occurred in 24%, and 11 patients died. Conclusions The dunking technique is easily adaptable, less time-consuming, and can be performed in the pancreas of any texture or duct size but is associated with an increased incidence of post-pancreatectomy hemorrhage. Incorporation of Braun's anastomosis lowers DGE, allows early initiation of feeding, and reduces complication rates.

Algorithm of surgical treatment for diaphyseal defects of the forearm bones due to gunshot injuries

Introduction In the current system of providing medical aid to wounded servicemen, along with the conservative primary surgical treatment and minimally invasive extrafocal fixation, high-tech surgical interventions of considerable complexity with the use of additive and tissue-engineering technologies have been coming to the forefront. It is necessary to determine their place in the current algorithm of limb bone defect management, which was the substantiation of our study.The purpose of the study was to improve the algorithm for selecting a treatment method for patients with associated gunshot defects of the forearm based on the literature and clinical observations.Materials and Methods We analyzed scientific articles in PubMed and Scientific Electronic Library (eLIBRARY.ru) platforms, published from 2004 to 2024, on the basis of which we could refine the algorithm of treatment method selection for patients with associated gunshot defects of the forearm. The developed algorithm was used to treat 178 patients with gunshot fractures of the forearm.Results The review of the literature established the main provisions and principles that are applied in the reconstruction of the forearm with an associated defect. When choosing the method of bone defect management, a great number of authors tend to build a “reconstructive ladder”, moving from less severe (one bone) and extended defects (small defect up to 2 cm) to more complex (both bones) and massive defect (more than 10 cm). Upon having considered the revealed regularities, we improved the algorithm of surgical treatment of the latter, which is based on two classification principles: defect extention and location. Reconstruction of the forearm as a dynamic system after diaphyseal fractures requires consider the state of the radioulnar joint. The function of the latter depends on the length ratio of the radius and ulna bones. Therefore, we substantiated small (up to 2 cm) forearm bone defects that can be managed by simple surgical methods. Another fundamental addition to the algorithm was the allocation of a patients’ group with a defect of one forearm bone and a fracture of the other bone (defect-fracture); this combination allows avoiding complex surgical methods for reconstruction and use segment shortening.Discussion The treatment of associated forearm defects is challenging, the choice of reconstruction technique remains uncertain, and the required consensus is lacking. Several forearm reconstruction techniques are available, yet there is no reliable evidence of their effectiveness in terms of treatment time, complications, reoperations, and functional recovery.Conclusion The algorithm proposed for the treatment of extensive gunshot-associated defects of the forearm allows us to consider the change in the anatomy, make a surgical plan based on the reconstruction vector, and select optimal surgical techniques.

Differential effect of surgical technique on intravesical recurrence after radical nephroureterectomy in patients with upper tract urothelial cancer: a systematic review and Meta-analysis

ContextRadical nephroureterectomy (RNU) with bladder cuff resection is the standard treatment in patients with high-risk upper tract urothelial cancer (UTUC). However, it is unclear which specific surgical technique may lead to improve oncological outcomes in term of intravesical recurrence (IVR) in patients with UTUC.ObjectiveTo evaluate the efficacy of surgical techniques and approaches of RNU in reducing IVR in UTUC patients.Evidence AcquisitionThree databases were queried in January 2024 for studies analyzing UTUC patients who underwent RNU. The primary outcome of interest was the rate of IVR among various types of surgical techniques and approaches of RNU.Evidence SynthesisThirty-one studies, comprising 1 randomized controlled trial and 1 prospective study, were included for a systematic review and meta-analysis. The rate of IVR was significantly lower in RNU patients who had an early ligation (EL) of the ureter compared to those who did not (HR: 0.64, 95% CI: 0.44–0.94, p = 0.02). Laparoscopic RNU significantly increased the IVR compared to open RNU (HR: 1.28, 95% CI: 1.06–1.54, p < 0.001). Intravesical bladder cuff removal significantly reduced the IVR compared to both extravesical and transurethral bladder cuff removal (HR: 0.65, 95% CI: 0.51–0.83, p = 0.02 and HR: 1.64, 95% CI: 1.15–2.34, p = 0.006, respectively).ConclusionsEL of the affected upper tract system, ureteral management, open RNU, and intravesical bladder cuff removal seem to yield the lowest IVR rate in patients with UTUC. Well-designed prospective studies are needed to conclusively elucidate the optimal surgical technique in the setting of single post-operative intravesical chemotherapy.

Clinical application of eight-zone laparoscopic dissection strategy for rectal cancer: Experience and discussion.

The incidence of rectal cancer is increasing worldwide, and surgery remains the primary treatment modality. With the advent of total mesorectal excision (TME) technique, the probability of tumor recurrence post-surgery has significantly decreased. Surgeons' focus has gradually shifted towards minimizing the impact of surgery on urinary and sexual functions. Among these concerns, the optimal dissection of the rectal lateral ligaments and preservation of the pelvic floor neurovascular bundle have become critical. To explore the optimal surgical technique for TME and establish a standardized surgical protocol to minimize the impact on urinary and sexual functions, we propose the eight-zone dissection strategy for pelvic floor anatomy. To compare the differences in surgical specimen integrity and postoperative quality of life satisfaction between the traditional pelvic floor dissection strategy and the innovative eight-zone dissection strategy. We analyzed the perioperative data of patients who underwent laparoscopic radical resection of rectal cancer at Qilu Hospital of Shandong University between January 1, 2021 and December 1, 2023. This study included a total of 218 patients undergoing laparoscopic radical surgery for rectal cancer, among whom 109 patients underwent traditional pelvic floor dissection strategy, and 109 patients received the eight-zone dissection strategy. There were no significant differences in general characteristics between the two groups. Patients in the eight-zone dissection group had higher postoperative specimen integrity (88.1% vs 78.0%, P = 0.047). At the 3-month follow-up, patients in the eight-zone surgery group had better scores in urinary issues (6.8 ± 3.3 vs 5.3 ± 2.5, P = 0.045) and male sexual desire (2.2 ± 0.6 vs 2.5 ± 0.5, P = 0.047) compared to the traditional surgery strategy group. This study demonstrates that the eight-zone dissection strategy for laparoscopic lateral ligament dissection of rectal cancer is safe and effective. Compared with the traditional pelvic floor dissection strategy, this approach can reduce the risk of nerve injury and minimize the impact on urinary and sexual functions. Therefore, we recommend the clinical application of this strategy to better serve patients with rectal cancer.

Microsurgical Repair of Ventral Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension: Efficacy and Safety of Patch-Sealing Versus Suturing.

In patients with spontaneous intracranial hypotension (SIH), microsurgical repair is recommended in Type 1 (ventral) dural leaks, when conservative measures fail. However, there is lacking consensus on the optimal surgical technique for permanent and safe closure of ventral leaks. We performed a retrospective analysis of surgically treated SIH patients with Type 1 leaks at our institution between 2013 and 2023. Patients were analyzed according to the type of surgical technique: (1) Microsurgical suture vs (2) extradural and intradural patching (sealing technique). End points were resolution of spinal longitudinal epidural cerebrospinal fluid collection (SLEC), change in brain SIH-Score (Bern-Score), headache resolution after 3 months, surgery time, complications, and reoperation rates. In total, 85 (66% women) patients with consecutive SIH (mean age 47 ± 11 years) underwent transdural microsurgical repair. The leak was sutured in 53 (62%) patients (suture group) and patch-sealed in 32 (38%) patients (sealing group). We found no significant difference in the rates of residual SLEC and resolution of headache between suture and sealing groups (13% vs 22%, P = .238 and 89% vs 94%, P = .508). No changes were found in the postoperative Bern-Score between suture and sealing groups (1.4 [±1.6] vs 1.7 [±2.1] P = 1). Mean surgery time was significantly shorter in the sealing group than in the suture group (139 ± 48 vs 169 ± 51 minutes; P = .007). Ten patients of the suture and 3 of the sealing group had a complication (23% vs 9%, P = .212), whereas 6 patients of the suture and 2 patients of the sealing group required reoperation (11% vs 6%, P = .438). Microsurgical suturing and patch-sealing of ventral dural leaks in patients with SIH are equally effective. Sealing alone is a significantly faster technique, requiring less spinal cord manipulation and may therefore minimize the risk of surgical complications.

Neurectomy for allergic rhinitis in Japan: Increasing trends and surgeon preferences

ObjectiveThere is no consensus on the optimal surgical technique for allergic rhinitis (AR). Furthermore, the appropriateness of surgical intervention in children and older individuals remains debatable. This study aimed to analyze trends and patterns in the surgical management of AR in Japan, focusing on parasympathetic neurectomy. MethodsUsing the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), we conducted a comprehensive review of procedures performed between April 2014 and March 2022. In addition, a cross-sectional survey targeting otolaryngologists across Japan was conducted to gather insights into surgical preferences and practices. ResultsThe NDB data showed an increasing trend in neurectomies, with the most frequent age group being 25–29 years; the procedure was also performed in pediatric and older patients. The survey among otolaryngologists indicated that 58.2 % of surgeons preferred peripheral branch neurectomy of the posterior nasal nerve. The findings of this study also indicated a cautious approach toward conducting these procedures in children, with 51.2 % of surgeons considering patients less than 18 years of age unsuitable for the procedure. ConclusionThis study highlighted a shift toward simple and minimally invasive surgical methods, such as peripheral branch neurectomy, in Japan. However, further research is needed to understand the long-term outcomes and refine the surgical techniques. The findings of this study also emphasized the need for age-specific considerations when treating pediatric and older patients with AR.

P-738 Reproductive surgery for fertility preservation: Robotic single-port myomectomy (da Vinci® SP) versus robotic single-site myomectomy (da Vinci® Xi or Si)

Abstract Study question To compare clinical and surgical outcomes of robotic single-port myomectomy using da Vinci® SP and robotic single-site myomectomy with Xi or Si for fertility preservation. Summary answer The robotic single-port myomectomy (da Vinci® SP) might be feasible, even if the myoma is deep-seated, compared to robotic single-site myomectomy (Xi or Si system). What is known already Myomas are clinically apparent in about 25% of women and become symptomatic in their reproductive age. Myomectomy is the choice of treatment for women desiring uterine preservation, especially in deep-seated fibroid that can affect pregnancy. Although young women prefer minimal invasive surgical technique with less scar, single-port laparoscopic myomectomy has some limitations. Adoption of the da Vinci® system made it possible to overcome the weaknesses of laparoscopy. Owing to the ability of single-port laparoscopy to reduce pain and improve patient satisfaction, robotic single-site surgery was developed in order of the da Vinci® Si, Xi and the latest new SP system. Study design, size, duration We retrospectively reviewed medical records of 214 patients who underwent robotic single-port myomectomy (RSPM, n = 111) using the da Vinci® SP surgical system or robotic single-site myomectomy (RSSM, n = 103) with the da Vinci® Xi or Si system between October 2015 and September 2023 at Ewha Womans University Mokdong Hospital. Baseline characteristics and operative outcomes were compared and analyzed between the RSPM and RSSM groups. Participants/materials, setting, methods We assessed FIGO classification and maximum diameter of fibroid. The incision time, docking time, console time, wound closure time, total operation time, estimated blood loss (EBL), chopping time for specimen removal, the number and weight of removed myoma were measured. Main results and the role of chance Mean age (38.5±6.6 vs 37.3±6.6 years) and anthropometric index were not significantly different between RSPM and RSSM groups. Although the diameter (7.1±1.4 vs 7.2±2.0 cm), number (3.1±2.7 vs 2.5±2.2), and weight (149.1±107.1 vs 146.4±130.6 g) of myoma were not significantly different between the two groups, the more deep-seated myoma diagnosed by FIGO classification (2.9±1.5 vs 4.6±2.0, p&amp;lt;0.0001) could be resected in RSPM group. The incision (3.6±1.9 vs 7.3±4.4 min, p &amp;lt;0.0001) and docking time (2.7±1.4 vs 4.6±1.6 min. p&amp;lt;0.0001) were less in the group of RSPM compared to RSSM that was earlier implementation. Depending on the differences in da Vinci® SP and Xi or Si systems, the wound was slightly larger, requiring shorter chopping time (6.4±5.0 vs 8.4±7.2 min, p=0.022) and longer closure time (12.8±4.4 vs 10.9±3.6 min, p=0.001) in the RSPM group. Additionally, more complex surgeries with larger blood loss (264.1±140.2 vs 176.8±132.0 ml, p&amp;lt;0.0001), longer console time (60.5±33.2 vs 49.7±22.6 min, p=0.016) and hospitalization (4.6±0.9 vs 4.3±0.6 days, p=0.005) were performed in the RSPM group, but the difference in hemoglobin (2.5±1.0 vs 2.6±0.9 g/dL) before and after surgery was not significant. Limitations, reasons for caution All surgeries underwent using the da Vinci systems by one gynecologic surgeon who had experience performing almost 2,000 gynecologic robotic surgeries and the follow-up period was not enough to conclude the reproductive outcome. Wider implications of the findings The RSPM using the da Vinci® SP surgical system could be recommended for patient who planned future pregnancy. However, the optimal surgical technique should be selected for successful fertility preservation of reproductive surgery. Trial registration number 2023-03-038

Comparative on the effectiveness and safety of different carotid endarterectomy techniques: a single-center Retrospective Study

BackgroundCarotid endarterectomy (CEA) is a surgical procedure that can reduce the risk of stroke in patients with carotid artery stenosis. However, controversy still exists regarding the optimal surgical technique for CEA.ObjectiveTo compare the safety and effectiveness of different techniques.MethodsData on baseline characteristics as well as perioperative and postoperative complications from patients who underwent CEA at the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, were retrospectively collected and analyzed.ResultsA total of 262 CEA patients included in study, with a total of 265 CEA operations. The mean age of 69.95 ± 7.29 (range, 44–89) years. 65 (24.5%) patients underwent cCEA, 94 (35.5%) underwent pCEA, and 106 (40.0%) underwent eCEA. The use of shunt (1.9%) and the mean operation time were lower in eCEA group (P < 0.05). eCEA was also associated with a lower incidence of postoperative hypotension, whereas pCEA was associated with a lower incidence of postoperative hypertension (P < 0.05). There was no significant difference in clinical baseline characteristics, occurrence of perioperative complications, and survival whether restenosis-free, asymptomatic or overall.ConclusionsThis study found that all three surgical methods are equally safe for the treatment of carotid artery stenosis and are effective in preventing stroke.

Surgical delay in abdominal based flap surgery: a scoping review.

The abdominal donor site is the most common flap used for breast reconstruction, with flap necrosis a feared complication. The technique of surgical 'delay' involves the inducing of relative ischemia to promote neovascularisation, amongst other metabolic adaptations, and has been used to augment flap vascularity and reduce this complication. There is significant variability in the manner in which flap surgery and surgical delay may be performed, such as the vessels ligated, the presence and degree of flap elevation, and the decision to harvest muscle with the flap, amongst other factors. A formal review of techniques, however, has not yet been performed, and there is no consensus as to the optimal technique for surgical delay. A scoping review of the current literature was undertaken to determine the optimal surgical delay technique in abdominal-based flap surgery. A literature search was conducted across PubMed, Embase, Cochrane, and Medline databases. Data regarding the type of flap surgery, delay techniques, and corresponding clinical outcomes was collected and categorised by technique type. Nine studies met the inclusion criteria and were included for review. Levels of evidence and rates of complications were compared. The range of surgical delay techniques reported in the literature was described. Surgical delay was found to reduce overall complication rates, and the available data suggests it may be particularly beneficial in high-risk patients. The current data support delay as a viable method for reducing rates of complications. Further studies and data are required to compare surgical delay techniques and determine the benefit delay may pose to patients with risk factors.

Management of Meniscus Pathology with Concomitant Anterior Cruciate Ligament Injury.

The purpose of this review is to summarize current clinical knowledge on the prevalence and types of meniscus pathology seen with concomitant anterior cruciate ligament (ACL) injury, as well as surgical techniques, clinical outcomes, and rehabilitation following operative management of these pathologies. Meniscus pathology with concomitant ACL injury is relatively common, with reports of meniscus pathology identified in 21-64% of operative ACL injuries. These concomitant injuries have been associated with increased age and body mass index. Lateral meniscus pathology is more common in acute ACL injury, while medial meniscus pathology is more typical in chronic ACL deficiency. Meniscus tear patterns associated with concomitant ACL injury include meniscus root tears, lateral meniscus oblique radial tears of the posterior horn (14%), and ramp lesions of the medial meniscus (8-24%). These meniscal pathologies with concomitant ACL injury are associated with increased rotational laxity and meniscal extrusion. There is a paucity of comparative studies to determine the optimal meniscus repair technique, as well as rehabilitation protocol, depending on specific tear pattern, location, and ACL reconstruction technique. There has been a substantial increase in recent publications demonstrating the importance of meniscus repair at the time of ACL repair or reconstruction to restore knee biomechanics and reduce the risk of progressive osteoarthritic degeneration. Through these studies, there has been a growing understanding of the meniscus tear patterns commonly identified or nearly missed during ACL reconstruction. Surgical management of meniscal pathology with concomitant ACL injury implements the same principles as utilized in the setting of isolated meniscus repair alone: anatomic reduction, biologic preparation and augmentation, and circumferential compression. Advances in repair techniques have demonstrated promising clinical outcomes, and the ability to restore and preserve the meniscus in pathologies previously deemed irreparable. Further research to determine the optimal surgical technique for specific tear patterns, as well as rehabilitation protocols for meniscus pathology with concomitant ACL injury, is warranted.