Suture Placement Research Articles

Chronic Periodontal Infection and Not Iatrogenic Interference Is the Trigger of Medication-Related Osteonecrosis of the Jaw: Insights from a Large Animal Study (PerioBRONJ Pig Model).

Background and Objectives: Antiresorptive drugs are widely used in osteology and oncology. An important adverse effect of these drugs is medication-induced osteonecrosis of the jaw (MRONJ). There is scientific uncertainty about the underlying pathomechanism of MRONJ. A promising theory suspects infectious stimuli and local acidification with adverse effects on osteoclastic activity as crucial steps of MRONJ etiology. Clinical evidence showing a direct association between MRONJ and oral infections, such as periodontitis, without preceding surgical interventions is limited. Large animal models investigating the relationship between periodontitis and MRONJ have not been implemented. It is unclear whether the presence of infectious processes without surgical manipulation can trigger MRONJ. The following research question was formulated: is there a link between chronic oral infectious processes (periodontitis) and the occurrence of MRONJ in the absence of oral surgical procedures? Materials and Methods: A minipig large animal model for bisphosphonate-related ONJ (BRONJ) using 16 Göttingen minipigs divided into 2 groups (intervention/control) was designed and implemented. The intervention group included animals receiving i.v. bisphosphonates (zoledronate, n = 8, 0.05 mg/kg/week: ZOL group). The control group received no antiresorptive drug (n = 8: NON-ZOL group). Periodontitis lesions were induced by established procedures after 3 months of pretreatment (for the maxilla: the creation of an artificial gingival crevice and placement of a periodontal silk suture; for the mandible: the placement of a periodontal silk suture only). The outcomes were evaluated clinically and radiologically for 3 months postoperatively. After euthanasia a detailed histological evaluation was performed. Results: Periodontitis lesions could be induced successfully in all animals (both ZOL and NON-ZOL animals). MRONJ lesions of various stages developed around all periodontitis induction sites in the ZOL animals. The presence of MRONJ and periodontitis was proven clinically, radiologically and histologically. Conclusions: The results of this study provide further evidence that the infectious processes without prior dentoalveolar surgical interventions can trigger MRONJ. Therefore, iatrogenic disruption of the oral mucosa cannot be the decisive step in the pathogenesis of MRONJ.

(356) Microsurgical Training in a High-volume Academic Infertility Practice. What we Learn from the Residents

Abstract Introduction Surgical education has been traditionally rooted in the apprenticeship model, where the experts teach the surgeons-in-training during real-time surgeries. With the advent of robotics, the emphasis on simulation and virtual reality training is upon us. Objective The goal of this study is to examine lessons learned from the first few years of our institution’s microsurgical training. Methods A structured resident male infertility microsurgical training program was devised and multiple attempts at implementing it were made. When resident lack of interest/ time availability as well as COVID pandemic factored in, adjustments were made. And the devised assessment was applied to real-time surgeries. A structured assessment of the trainee’s skills was used by the faculty surgeon at initiation of the training, and throughout. All aspects of the assessment were evaluated on the scale of 1-5, with 1 being the lowest and 5 the highest. (Table 1) According to the individual improvement, the difficulty of the skills and steps of the procedure were advanced accordingly. This evaluation was not communicated with the trainees in order to avoid their undue stress/ intimidation. Results A total of 78 microscopic vasectomy reversal surgeries were performed by one staff surgeon and four consecutive resident surgeons between January 2020 and May 2022. All residents were in their 2nd year of Urology training (PGY-2). On average, each of the trainees participated in 17 vasectomy reversals (13-21), with similar amount of surgical time spent (about 3-4 hrs/ case). At initiation of their training, each individual had similar basic and microscopic surgical skills, procedure knowledge, economy of motion and tissue/ instrument/ needle handling ability (scores of 2-3 out of 5). Two of the trainees displayed higher level of interest and better listening skills, which resulted in willingness to correct their errors and ultimately improve on their surgical techniques. The resident with initial poor skill set and poor interest/ listening skills did not progress to more advanced stages of training and was relegated to initial dissection/ exposure and placement of adventitial sutures. The resident with slightly better surgical skills but unwilling to make corrections to his technique, progressed to the next level of placing occasional luminal sutures. The remaining two residents displayed the most interest, involvement and receptiveness to the feedback. They both progressed to the final stages of the training, with one of them performing the entire operation as a primary surgeon, with the staff assisting. (Table 2). Conclusions While the structured residency microsurgical training program is of utmost importance, competing professional and personal interests of the resident-surgeons may affect its full execution. Careful observation of the trainees, their skills, ability to receive and process the feedback in combination with teaching faculty’s patience and flexibility are paramount to the safe and effective “real-life” training. When devising a surgical training program it is important to keep in mind that surgical residents prefer hands-on operating experiences. Disclosure No

Corneal Hydrops - Aetiology and Advanced Therapeutic Strategies.

Acute hydrops refers to sudden corneal edema caused by rupture of Descemet's membrane (DM) - often in progressive keratectasia. It leads to a sudden decrease in visual acuity, pain, and foreign body sensation as well as an increased glare sensation. Acute hydrops usually heals with scarring within months, but complications such as corneal perforation, infectious keratitis, and corneal vascularization may occur. The prevalence in keratoconus patients is 2.6 to 2.8%. Risk factors include keratoconjunctivitis vernalis, atopic dermatitis, high keratometry, male gender, and eye rubbing. Keratoplasty should be avoided in the acute phase. The prognosis of the graft is reduced, and after scar healing of the hydrops, wearing contact lenses or glasses may be possible again. Conservative therapy alone with lubricants and hyperosmolar eye drops, prophylactic antibiotic eye drops to prevent superinfection, and topical steroids was long considered the only possible form of treatment. However, healing under conservative therapy takes an average of over 100 days. In the meantime, there are different surgical strategies that rapidly shorten the healing and thus the recovery phase of the patients to a few days. If the DM is detached without tension, a simple injection of gas into the anterior chamber can already lead to reattachment and thus to almost immediate deswelling of the cornea. If the DM is under tension, predescemetal sutures combined with a gas injection into the anterior chamber can flatten the cornea and reattach the DM. Mini-Descemet membrane endothelial keratoplasty (mini-DMEK) allows for sutureless closure of the DM defect by transplantation of a small (< 5 mm) graft. In cases of particularly large DM tears and very pronounced hydrops, suture loosening and relapse may occur after the placement of predescemetal sutures. Mini-DMEK can then lead to permanent healing, but in contrast to simple corneal sutures, it is usually performed under general anesthesia and by aid of intraoperative optical coherence tomography. The very good results with regard to the rapid healing prove that surgical therapy makes sense in the vast majority of patients with acute hydrops and should be initiated quickly.

External airway splint placement for severe pediatric tracheobronchomalacia

ObjectiveTo present external airway splinting with bioabsorbable airway supportive devices (ASD) for severe, life-threatening cases of pediatric tracheomalacia (TM) or tracheobronchomalacia (TBM). MethodsA retrospective cohort was performed for 5 pediatric patients with severe TM or TBM who underwent ASD placement. Devices were designed and 3D-printed from a bioabsorbable material, polycaprolactone (PCL). Pre-operative planning included 3-dimensional airway modeling of tracheal collapse and tracheal suture placement using nonlinear finite element (FE) methods. Pre-operative modeling revealed that triads along the ASD open edges and center were the most effective suture locations for optimizing airway patency. Pediatric cardiothoracic surgery and otolaryngology applied the ASDs by suspending the trachea to the ASD with synchronous bronchoscopy. Respiratory needs were trended for all cases. Data from pediatric patients with tracheostomy and diagnosis of TM or TBM, but without ASD, were included for discussion. ResultsFive patients (2 Females, 3 Males, ages 2–9 months at time of ASD) were included. Three patients were unable to wean from respiratory support after vascular ring division; all three weaned to room air post-ASD. Two patients received tracheostomies prior to ASD placement, but continued to experience apparent life-threatening events (ALTE) and required ventilation with supraphysiologic ventilator settings. One patient weaned respiratory support successfully after ASD placement. The last patient died post-ASD due to significant respiratory co-morbidity. ConclusionASD can significantly benefit patients with severe, unrelenting tracheomalacia or tracheobronchomalacia. Proper multidisciplinary case deliberation and selection are key to success with ASD. Pre-operative airway modeling allows proper suture placement to optimally address the underlying airway collapse.

Laparoscopic Multiport Inguinal Hernia Repair in a Male Infant

Inguinal hernias in infants and children may be treated with open surgery or laparoscopy. First performed in 1993 more and more pediatric surgeons in western countries use the laparoscopic technique, at least in older children. Laparoscopic repair may be performed by either intra- or extra corporeal closure of the open processus vaginalis. The intra-corporeal method uses an intracorporeal suture with the help of three ports while the extra-corporeal closure uses a suture that is passed over two needles and the knot is tied manually outside the patient without the need for an additional port. We hereby describe step by step the laparoscopic multiport inguinal hernia repair in a male infant. This includes positioning of patient and trocars, incision of the peritoneum and placement of a non-absorbable braided purse-string suture at the inner inguinal ring, and intracorporal knot tying using the laparoscopic sliding knot. Minimally invasive hernia surgery in children is a common and technically demanding operation that lends itself well to teaching residents.

Surgical closure of cleft palate defects in dogs using a modification of the traditional von Langenbeck technique: 12 cases (2015-2022).

To describe the author's surgical guidelines for the effective use of a modified von Langenbeck technique, utilizing bilateral bipedicle mucoperiosteal flaps in the dog. 12 client-owned dogs with cleft palate defects of the hard and soft palates. 12 dogs with cleft palate were presented to the Angell Animal Medical Center from May 20, 2015, to March 24, 2022. The patient's ages ranged from 5 months to 3 years. All 12 dogs had closure of the hard palate clefts by use of modifications of the original von Langenbeck technique in this prospective study. Successful closure of the cleft (hard and soft) palate defects was achieved in all 12 dogs in a single surgical procedure. A small residual opening was noted at the level of the incisive papilla in each dog; this was of no clinical consequence in this report. The von Langenbeck technique, using the simple closure modifications reported, was effective in closing both narrow and wide defects. Successful execution requires the complete elevation of each flap, which facilitates their tension-free advancement over the palatal cleft. Vertical mattress sutures evert the flap margins, allowing for direct collagen surface contact for proper healing. Placement of sutures in the rugal folds increases the tissue purchase to reduce the risk of suture cut-out. Fine interrupted sutures, placed between the vertical mattress sutures, maintains the proper alignment of the incisional margins. The author waits a minimum of 5 months before closing cleft palate defects, enabling the donor areas time to mature and improving their ability to retain sutures more effectively.

MP68-09 VALIDATION OF AN OBJECTIVE PRESSURE TEST FOR URETHROVESICAL ANASTOMOSIS IN A NON-BIOHAZARDOUS ROBOT ASSISTED RADICAL PROSTATECTOMY SIMULATION MODEL

You have accessJournal of UrologyCME1 Apr 2023MP68-09 VALIDATION OF AN OBJECTIVE PRESSURE TEST FOR URETHROVESICAL ANASTOMOSIS IN A NON-BIOHAZARDOUS ROBOT ASSISTED RADICAL PROSTATECTOMY SIMULATION MODEL Nathan Schuler, Alexis Steinmetz, Kit Yuen, Lauren Shepard, Tyler Holler, Christopher Wanderling, and Ahmed Ghazi Nathan SchulerNathan Schuler More articles by this author , Alexis SteinmetzAlexis Steinmetz More articles by this author , Kit YuenKit Yuen More articles by this author , Lauren ShepardLauren Shepard More articles by this author , Tyler HollerTyler Holler More articles by this author , Christopher WanderlingChristopher Wanderling More articles by this author , and Ahmed GhaziAhmed Ghazi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003331.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urethrovesical Anastomosis (UVA) is a critical step within Robot Assisted Radical Prostatectomy (RARP) which directly influences postoperative complication and continence recovery. The current standard for assessing UVA proficiency is mainly through the Robotic Anastomosis Competency Evaluation (RACE), a subjective video-based grading system. We have previously validated embedded force sensors within realistic RARP models as an objective method to measure torque during nerve sparing. Herein, we developed an adjacent pressure test with parallels to common urodynamic testing as an objective metric to evaluate UVA integrity in our RARP simulation. METHODS: 48 simulated robotic UVA were completed by urologists with varying experience levels: 6 experts (EXP), 16 intermediates (IM) and 26 novices (NOV)). Following simulation, bladders were dissected from surrounding tissue and subjected to a pressure leak test. Bladders were filled to predetermined volumes at a constant rate. Internal volume when leakage at the UVA site started and at end of filling were measured, then used to calculate maximum internal pressure (Pmax) and pressure at leakage start (Pleak). Flow Fractionation (FF) was calculated by allowing free fluid flow through both UVA site and urethra onto separate, tared scales and recorded throughout the test. RACE scores were assigned by two blinded expert video reviewers. RESULTS: EXP showed higher Pmax, FF, and Pleak versus NOV (p=.0009; p=.005; p=.011) as well as EXP vs IM (p=.028; p=.047; p=.047), however IM vs NOV lacked significance. Multivariate analysis found significant positive correlations between Knot Tying (KT), Suture Placement (SP) and Tissue Approximation (TA) with FF (p=.017; p=.051; p=.0007) and Pmax (p=0.01; p=.087; p=.0005). TA and KT had significant correlations with Pleak (p=.0027; p=.085) (Figure 1). CONCLUSIONS: The bladder pressure test and its parameters we have developed represent three objective metrics that can be used to assess the ability of a trainee to complete a UVA that would succeed in an intraoperative leak test. Stratification of test difficulty towards the upper end of the RACE score spectrum offers more granularity by which intermediates can assess performance vs experts. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e956 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Schuler More articles by this author Alexis Steinmetz More articles by this author Kit Yuen More articles by this author Lauren Shepard More articles by this author Tyler Holler More articles by this author Christopher Wanderling More articles by this author Ahmed Ghazi More articles by this author Expand All Advertisement PDF downloadLoading ...

V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE

You have accessJournal of UrologyCME1 Apr 2023V04-05 ROBOT-ASSISTED LAPAROSCOPIC EXTRAVESICAL BILATERAL URETERAL REIMPLANTATION: LUAA TECHNIQUE Parviz Hajiyev, Jared Fialkoff, and Mohan Gundeti Parviz HajiyevParviz Hajiyev More articles by this author , Jared FialkoffJared Fialkoff More articles by this author , and Mohan GundetiMohan Gundeti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In today's era of minimally invasive surgery, robotic-assisted laparoscopic ureteral reimplantation (RALUR) is being popularly performed at many centers. We previously described the LUAA technique (Eur Urol 2016; 70(5):818–823). METHODS: Through this video, we share the step-by-step technical details of the “LUAA” (L-length of ureteric tunnel, U- the u stitch at UVJ, A- placement of the ureteral apical alignment suture and A- ensuring inclusion of adequate ureteral adventitia in detrusorrhaphy) for bilateral ureteric reimplantation. A 4 years old girl presented with recurrent urinary tract infections (UTI) . Her voiding cystourethrogram (VCUG) was suggestive of bilateral high grade of vesicoureteric reflux (VUR), and DMSA scan showed multiple scars. RESULTS: For this persistent bilateral VUR with breakthrough UTIs beyond the age of toilet training, she underwent a robotic-assisted laparoscopic ureteric reimplantation- bilateral (RALUR-b) by the “LUAA” technique. CONCLUSIONS: Postoperative she had USS one month and one year and was normal. The VCUG at 4 months showed resolved VUR bilateral. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e339 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Parviz Hajiyev More articles by this author Jared Fialkoff More articles by this author Mohan Gundeti More articles by this author Expand All Advertisement PDF downloadLoading ...

V08-09 TRANSURETHRAL DORSAL BUCCAL GRAFT URETHROPLASTY FOR PROXIMAL FEMALE URETHRAL STRICTURES

You have accessJournal of UrologyCME1 Apr 2023V08-09 TRANSURETHRAL DORSAL BUCCAL GRAFT URETHROPLASTY FOR PROXIMAL FEMALE URETHRAL STRICTURES Francis Jefferson, Jonathan Warner, Maraika Robinson, and Brian Linder Francis JeffersonFrancis Jefferson More articles by this author , Jonathan WarnerJonathan Warner More articles by this author , Maraika RobinsonMaraika Robinson More articles by this author , and Brian LinderBrian Linder More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003306.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Treatment options for proximal female urethral strictures have significant limitations such as high recurrence rate (urethral dilation) and de novo stress urinary incontinence (flap/graft reconstruction). The objective of this video was to describe a novel dorsal inlay buccal graft urethroplasty technique that reduces technical difficulty and eliminates the need for urethral mobilization. METHODS: Stay sutures are placed at the urethral meatus, and a nasal speculum is placed into the urethra staying distal to the stricture. A beaver blade is then used to incise the urethra at the 12 o'clock, 10 o’clock, and 2 o’clock positions; these are superficial, non-full thickness incisions. A laparoscopic suture passing device is then used to pass a suture from the bladder to the urethral lumen at the 12:00 o'clock position. The suture is then passed through corresponding mid portion of the buccal graft ensuring that the mucosal side will be in the urethral lumen when the graft is deployed. This is repeated at the 10 o'clock and 2 o'clock positions with placement of the proximal suture at the level of the bladder neck and then through the corresponding location on the buccal graft. The graft is then parachuted into position at the level of the bladder neck. A laparoscopic knot pusher is then used to tie down the proximal sutures through the urethra. After trimming the excess buccal graft flush with the meatus, the distal aspect of the graft is sutured to the vaginal epithelium to recreate the urethral meatus. A wide-bore catheter is placed for 3 weeks postoperatively. RESULTS: In 6 consecutive patients treated with this technique with a median follow-up of 3.9 months, surgical success has been 100% as indicated by urethral patency on cystourethroscopy and subjective symptom improvement. There have been no cases of de novo stress urinary incontinence. Pre- and post-operative maximum urine flow rate (Qmax) and post-void residual volumes (PVR) are shown in the table. CONCLUSIONS: A transurethral inlay approach for dorsal buccal graft placement is a feasible option for management of female proximal urethral structure. Given decreased periurethral dissection compared to other techniques, this approach may decrease the risk of de novo stress urinary incontinence. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e751 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Francis Jefferson More articles by this author Jonathan Warner More articles by this author Maraika Robinson More articles by this author Brian Linder More articles by this author Expand All Advertisement PDF downloadLoading ...

V11-11 A 3-D PRINTED SYNTHETIC VAS DEFERENS FOR MICROSURGERY PRACTICE AND TRAINING

You have accessJournal of UrologyCME1 Apr 2023V11-11 A 3-D PRINTED SYNTHETIC VAS DEFERENS FOR MICROSURGERY PRACTICE AND TRAINING Parth Joshi, Brian Gillette, and Richard Schoor Parth JoshiParth Joshi More articles by this author , Brian GilletteBrian Gillette More articles by this author , and Richard SchoorRichard Schoor More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Microsurgery is difficult to perform and to teach. While other models for microsurgical practice exist, such as rubber tubing, dog neuter specimens, bull reproductive tracts, and human cadaver specimens, these are either not realistic enough to be useful as practice tools or are expensive or are not readily available. We believe that practicing microsurgery improves performance in real world conditions. As such, in order to become better microsurgeons ourselves and for our patients and to improve the quality of microsurgical training for our residents, we developed a synthetic vas deferens that has the physical characteristics of native human vas deferens. This video demonstrates the results of that endeavor. METHODS: We determined the physical characteristics of native human vas deferens in terms of inner lumen diameter, outer diameter, flexibility, axial rigidity, and tactile similarity using previously published anatomic studies, ultrastructural and imaging research and professional knowledge. We then used to a 3-D printer to create a cylindrical tube that had similar characteristics to native vas deferens and then tested it by performing anastomoses on the model using 7-0, 8-0, and 9-0 suture. After a process of trial and error, we eventually developed a working prototype that met our specifications. RESULTS: The synthetic 3-D printed vas deferens models had similar inner luminal diameter and outer diameter to native human vas deferens. The synthetic vas deferens had a similar tactile feel and physical characteristics as native vas. Surgical placement of 7-0, 8-0, and 9-0 nylon suture into the wall of the synthetic vas deferens and its lumen mimicked closely the experience of operating on native vas deferens. While tying good quality square knots was straightforward using 7-0 and 8-0 nylon suture, the synthetic vas deferens was too springy for the 9-0 suture and often resulted in either air-knots or suture breakage. However, by using excellent microsurgical techniques, it was possible to perform a quality modified one layer anastomosis using our 3-D printed synthetic vas deferens. The experience of practice with our model system simulated the experience of doing an actual anastomosis on a human. Aside for research and development costs, the cost for each synthetic vas specimen is less than $1.00 and the specimens have an unlimited shelf-life. CONCLUSIONS: The time to learn microsurgery or to practice it is not when the patient is on the operating table. We have developed a excellent, inexpensive, and readily available simulation vas deferens that is useful for both the experienced microsurgeon and the trainee or novice. Our research team is continually refining the synthetic vas deferens so that it becomes more lifelike and better accommodates 9-0 sutures and even everted 10-0 inner layer suture placement. Our goal is to share this technology with other training programs and standardize microsurgical education nationally and internationally. Source of Funding: Internal funding © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1002 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Parth Joshi More articles by this author Brian Gillette More articles by this author Richard Schoor More articles by this author Expand All Advertisement PDF downloadLoading ...

Bleeding and ketorolac use in pediatric circumcision.

Circumcision is a common surgical procedure performed in pediatric male patients. Ketorolac is an effective adjunct in multimodal regimens for postoperative pain control. However, many urologists and anesthesiologists refrain from administering ketorolac due to concern for postoperative bleeding. Compare the risk of clinically significant bleeding after circumcision with and without intraoperative ketorolac administration. A single-center, retrospective cohort study was conducted of pediatric patients 1-18 years of age who underwent isolated circumcision by one urologist from 2016 to 2020. Clinically significant bleeding was defined as bleeding requiring intervention within the first 24 h of circumcision. Interventions included use of absorbable hemostats, placement of sutures, or return to the operating room. Of 743 patients, 314 (42.3%) did not receive ketorolac and 429 (57.7%) received intraoperative ketorolac 0.5mg/kg. Postoperative bleeding requiring intervention occurred in one patient (0.32%) in the non-ketorolac group versus four patients (0.93%) in the ketorolac group (difference 0.6%, 95% CI [-0.8%, 2.0%], p=0.403). There was no statistically significant difference in postoperative bleeding requiring intervention between the non-ketorolac and ketorolac groups. Future studies regarding the association between ketorolac and postoperative bleeding are needed.

Sacrospinous fixation: Review of relevant anatomy and surgical technique.

Apical support is an important component of pelvic floor reconstruction for pelvic organ prolapse. Sacrospinous ligament fixation is a recognized procedure for apical support. Complications from sacrospinous ligament fixation include pain (buttock and leg) and bleeding. There is some debate as to the optimal location for placement of the sacrospinous fixation sutures. This review summarizes the neuroanatomy of the coccygeus sacrospinous ligament as it pertains to the sacrospinous ligament fixation procedure. An appreciation of the neuroanatomy will lead to a better understanding of methods to reduce operative complications and improve suture placement. This paper also describes a technique for the sacrospinous fixation procedure to better assist clinicians in dissecting the connective tissue off the ligament. Removing or clearing the connective tissue off the ligament will allow critical landmarks to be easily palpated and hence a more accurate placement of sutures. This in turn may reduce the risk of perioperative complications.

Endoscopic Gastric Sleeve: A Review of Literature.

For morbid obesity, one of the treatment options that have been deemed the most effective is bariatric surgery. Specifically, endoscopic sleeve gastrectomy (ESG) has emerged as one of the minimally invasive procedures for weight loss to be developed recently. In this procedure, there is the endoscopic placement of sutures in a quest to ensure reductions in the stomach volume. In this review, the main aim was to review the literature concerning ESG's efficacy and safety. Secondary sources of data were used and electronic databases were searched to identify articles focused on assessing the safety or efficacy of ESG. They included several databases such as Clinicaltrials.gov, Embase (Excerpta Medica Database), and MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online) to select relevant articles. Both the titles and abstracts of the articles were used to determine their inclusion or exclusion from the current review. Additionally, some keywords were used to search and obtain relevant articles such as: ESG, obesity, bariatric surgery, and total body weight loss. This review relied on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework for the identification of articles, screening, determination of eligibility, and inclusion and exclusion as deemed appropriate. From the findings, the review established that ESG is effective when used as an alternative intervention for obesity. The beneficial effects are felt particularly in terms of the procedure's capacity to ensure that the total body weight loss mean percentage is significant. Apart from the benefit of ensuring weight loss, ESG was also found to impair gastric emptying, pose metabolic effects that are key to controlling obesity-associated metabolic dysregulation, and the ability to increase satiety. However, the procedure was documented to yield a few adverse events in some studies. Some of the notable adverse events include pulmonary embolism, potential pneumoperitoneum, and possible post-procedure leak in the posterior aspect of the gastric fundus as sutures exert tension and also cause thin walls. Emerging as a minimally-invasive procedure, ESG is a cost-effective alternative through which weight loss can be achieved significantly in obese populations. It leads to a slowdown of gastric emptying, causes an increase in satiety, and leads to an improvement in the metabolic profile. Therefore, for obese individuals not undergoing bariatric surgery, ESG can be an ideal treatment option, including individuals in need of a bridge to surgery and also those diagnosed with moderate obesity. Overall, when it comes to the management of obesity, this review established that ESG provides a paradigm shift targeting existing therapeutic gaps.

The anatomy of the sacrospinous ligament: how to avoid complications related to the sacrospinous fixation procedure for treatment of pelvic organ prolapse.

Historically, the sacrospinous ligament (SSL) has been used to treat POP in order to restore the apical compartment through a posterior or an anterior vaginal approach. The SSL is located in a complex anatomical region, rich in neurovascular structures that must be avoided to reduce complications such as acute hemorrhage or chronic pelvic pain. The aim of this three-dimensional (3D) video describing the SSL anatomy is to show the anatomical concerns related to the dissection and the suture of this ligament. We conducted a research of anatomical articles about vascular and nerve structures located in the SSL region, in order to increase the anatomical knowledge and show the best placement of sutures to reduce complications related to SSL suspension procedures. We showed the medial part of the SSL to be most suitable for the placement of the suture during SSL fixation procedures, in order to avoid nerve and vessel injuries. However, nerves to the coccygeus and levator ani muscle can course on the medial part of the SSL, the portion of the SSL where we recommended to pass the suture. Knowledge of the SSL anatomy is crucial and during surgical training it is clearly indicated to stay far away (almost 2 cm) from the ischial spine to avoid nerve and vascular injuries.

How To Do It: Mitral Valve Translocation.

Mitral valve translocation (MVT) is a novel procedure that was developed to treat patients with severe, symptomatic, secondary mitral regurgitation (MR). MVT enhances leaflet coaptation by insertion of an autologous pericardial patch interposed between the mitral annulus and the native mitral leaflets. The patch substantially increases total leaflet surface area and creates supranormal coaptation. In addition, it relieves leaflet tethering by transposing the native valve deeper into the ventricle and decreases the circumference of the annulus. The enhanced coaptation produced by MVT may protect against recurrent MR in patients with continued adverse left ventricular remodeling. The procedural steps include detachment of the intact native mitral valve at the annulus, placement of interrupted pledgeted sutures around the annulus to secure the proximal aspect of the patch, and attachment of the native valve to the distal aspect of the patch using running suture. Follow-up of patients who have undergoing MVT is ongoing, with satisfactory short-term results, including sustained MR grades of ≤mild and 14 mm coaptation at 12 months.

Prevention of Mitral Ring Dehiscence by a Simple Modification of Suture Placement.

Ring dehiscence is a serious complication after mitral valve annuloplasty, tending to occur primarily from the posterior annulus. The tension on the ring sutures during the cardiac cycle is one of the suspected reasons; to minimize this tension, we apply four additional pledgeted sutures positioned supra-annularly at critical hinge points and could achieve a marked reduction of annular dehiscence since.

Improved suture pullout through genipin-coated sutures in human biceps tendons with spatially confined changes in cell viability

BackgroundThe suture-tendon interface often constitutes the point of failure in tendon suture repair. In the present study, we investigated the mechanical benefit of coating the suture with a cross-linking agent to strengthen the nearby tissue after suture placement in human tendons and we assessed the biological implications regarding tendon cell survival in-vitro. MethodsFreshly harvested human biceps long head tendons were randomly allocated to control (n = 17) or intervention (n = 19) group. According to the assigned group, either an untreated or a genipin-coated suture was inserted into the tendon. 24 h after suturing, mechanical testing composed of cyclic and ramp-to-failure loading was performed. Additionally, 11 freshly harvested tendons were used for short-term in vitro cell viability assessment in response to genipin-loaded suture placement. These specimens were analyzed in a paired-sample setting as stained histological sections using combined fluorescent/light microscopy. FindingsTendons stitched with a genipin-coated suture sustained higher forces to failure. Cyclic and ultimate displacement of the tendon-suture construct remained unaltered by the local tissue crosslinking. Tissue crosslinking resulted in significant cytotoxicity in the direct vicinity of the suture (<3 mm). At larger distances from the suture, however, no difference in cell viability between the test and the control group was discernable. InterpretationThe repair strength of a tendon-suture construct can be augmented by loading the suture with genipin. At this mechanically relevant dosage, crosslinking-induced cell death is confined to a radius of <3 mm from the suture in the short-term in-vitro setting. These promising results warrant further examination in-vivo.

Commentary: Scleral penetration or perforation during strabismus surgery.

Commentary: Scleral penetration or perforation during strabismus surgery.

Novel Modality of Endoluminal Anastomotic Integrity Assessment with Fluoroangiography After Left-sided Colorectal Resections

BackgroundSeveral methods have been described for the intraoperative evaluation of colorectal anastomotic integrity. Technological evolution has allowed to progress from basic mechanical methods to the use of more sophisticated techniques. This study describes a novel endoluminal modality of colorectal anastomotic assessment through the use of a Disposable Rigid Scope Introducer (DRSI) also allowing for intraoperative endoluminal perfusion evaluation by indocyanine green (ICG) fluoroangiography in patients undergoing left-sided colorectal resection.MethodsThe DRSI consists of an endoluminal introducer device made up of an insertion tube and port connected to an insufflation bulb to manually insufflate the sigmoid and rectum and is compatible with any laparoscopic camera, also allowing for ICG fluoroangiography for perfusion purposes.ResultsThe DRSI was successfully used to assess anastomotic integrity after left-sided colorectal resections performed in 16 consecutive patients. The DRSI allowed to visualize by fluoroangiography the quality of tissue perfusion at the anastomotic site in all cases, contributing to the decision of avoiding loop ileostomies in low rectal resections. In 2 cases, the DRSI showed the presence of significant anastomotic bleeding which was successfully controlled by laparoscopic suture placement. No adverse event resulted from the use of this device.ConclusionsThe DRSI combines direct endoluminal visualization of the anastomosis together with real-time evaluation of its blood flow. This device holds great potential for prompt intraoperative detection of anastomotic alterations, possibly reducing the risk of postoperative anastomotic bleeding or leaks related to mechanical construction/perfusion issues. Potential advantages of this device warrant larger cohort studies and prospective randomized trials.

Needle holders.

In previous centuries, surgical needles were hand held. Suturing was inevitably crude and hand-threaded needles were used to close wounds using silk, linen or, later, catgut stitches. Hand-held needles were curved or straight, as discussed in the next article. In Victorian times and into the mid-20th century, many surgeons performed wound closure, suture transfixion, tissue repair, and anastomoses with skills, employing hand-held needles. A few earlier needle holders were designed to grip straight or J-shaped needles end on, so as to push the needle points into tissues by a forward movement. However, with finer work in the evolving craft, requiring more accurate placement of sutures, instruments grasping a needle at right angles to the shafts of the holders became the preferred way of controlling smaller curved needles. Straight needles remain mainly hand-wielded and are pushed or dragged through the tissues. The correct positioning of the modern curved needle in the jaws of the holder should ideally be at two-thirds of the distance from the point of the needle. This is to allow adequate penetration by the needle and to prevent its buckling if placed too close to the non-working end. Care is always needed when mounting or dismounting the needle to avoid stick injuries.