Portal Technique Research Articles

A Hybrid Transtibial Technique Combines the Advantages of Anteromedial Portal and Transtibial Approaches: A Prospective Randomized Controlled Trial

Background: The anteromedial (AM) portal and transtibial (TT) approaches are 2 common anterior cruciate ligament (ACL) femoral tunnel drilling techniques, each with unique benefits and disadvantages. A hybrid TT (HTT) technique using medial portal guidance of a flexible TT guide wire has recently been described that may combine the strengths of both the AM portal and the TT approaches. Hypothesis: The HTT technique will achieve anatomic femoral tunnel apertures similar to the AM portal technique, with improved femoral tunnel length and orientation. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 30 consecutive patients with primary ACL tears were randomized to undergo the TT, AM portal, or HTT technique for femoral tunnel positioning at the time of reconstruction. All patients underwent 3-dimensional computed tomography of the operative knee at 6 weeks postoperatively. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as graft bending angles in the sagittal and coronal planes, were measured. Results: Tibial tunnel lengths and aperture positions were identical between the 3 groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regard to both height (P = .629) and depth (P = .582). By contrast, compared with the AM portal and HTT techniques, femoral apertures created with the TT technique were significantly higher (P < .001 and P < .001, respectively) and shallower (P = .014 and P = .022, respectively) in the notch. The mean femoral tunnel length varied significantly between the groups, measuring 35.2, 41.6, and 54.1 mm for the AM portal, HTT, and TT groups, respectively (P < .001). Last, there was no difference between the mean coronal (P = .190) and sagittal (P = .358) graft bending angles between the TT and HTT groups. By contrast, compared with the TT and HTT techniques, femoral tunnels created with the AM portal technique were significantly more angulated in the coronal plane (17.7° [P < .001] and 12.5° [P = .006], respectively) and sagittal plane (13.5° [P < .001] and 10.5° [P = .013], respectively). Conclusion: This prospective randomized controlled trial found that the HTT technique achieved femoral aperture positions equally as anatomic as the AM portal technique but produced longer, less angulated femoral tunnels, which may help reduce graft strain and mismatch. As such, this hybrid approach may represent a beneficial combination of both the TT and the AM portal techniques. Registration: NCT02795247 (ClinicalTrials.gov identifier)

"One stop" liver-focused endoscopy: EUS-guided portal pressure gradient measurement technique.

Referral for abnormal liver chemistry is one of the most frequently encountered reasons for visits to gastroenterologists and hepatologists, particularly given the versatility and vulnerability of the liver.1Kwo P.Y. Cohen S.M. Lim J.K. ACG clinical guideline: evaluation of abnormal liver chemistries.Am J Gastroenterol. 2017; 112: 18-35Crossref PubMed Scopus (395) Google Scholar Here, we present a 40-year-old man with class III obesity, essential hypertension, and hyperlipidemia who was referred for further diagnostic workup of his abnormal liver chemistry. Despite periods of significant weight loss, his liver transaminases had remained elevated over the prior 10 years (alanine aminotransferase 20-93 U/L, aspartate aminotransferase 20-71 U/L). Diagnostic workup included an abdominal ultrasound with evidence of hepatic steatosis and transient elastography (Fibroscan) that demonstrated a liver stiffness of 12.8 kPa, S3 (marked steatosis), and F3 (severe fibrosis). After reviewing the risks, benefits, and alternatives, the decision was made to perform an EGD to evaluate for stigmata of portal hypertension and an EUS to obtain a liver biopsy specimen and portal pressure gradient (PPG) measurements. The patient was intubated and remained in the supine position for the entirety of the procedure (Video 1, available online at www.VideoGIE.org). Initially, an EGD was performed, with no endoscopic evidence of varices or stigmata of portal hypertension. Next, the EUS examination was performed. The left lobe of the liver appeared diffusely hyperechoic, suggestive of steatosis. Real-time elastography was then performed on the left and right lobes of the liver to assess liver stiffness. The region of interest was positioned over the hepatic parenchyma, and an average of 10 measurements was obtained from each lobe of the liver. Mean liver stiffness was 11.5 kPa. The EchoTip Insight Portosystemic Pressure Gradient Measurement System (Cook Medical, Bloomington, Ind, USA) then was set up, involving a 25-gauge FNA needle, noncompressible tubing, a compact digital manometer, and heparinized saline solution. The middle hepatic vein was first identified and punctured using a transgastric approach. Once the needle tip was seen within the vessel, approximately 1 to 2 mL of heparinized saline solution was used to flush the needle. The pressure reading on the manometer was obtained and recorded once stable. This process was repeated a total of 3 times, including repeat flushes of heparinized saline solution to obtain the mean hepatic vein pressure measurement. Next, the umbilical portion of the left portal vein was identified, and using the aforementioned approach, the process was repeated 3 times to obtain the mean portal vein pressure measurement. The PPG was calculated by subtracting the mean hepatic vein pressure (16.4 mm Hg) from the mean portal vein pressure (23.4), which measured 7 mm Hg (consistent with preclinical portal hypertension). Last, EUS-guided liver biopsy was performed. Using a 19-gauge EUS–fine needle biopsy needle primed with heparin, we performed a transgastric puncture to obtain a sample from the left lobe of the liver. This process was then repeated using a transduodenal approach to obtain tissue from the right lobe of the liver. Liver core was then expressed onto a slide and sent to surgical pathology. The patient was discharged home after endoscopy without any adverse events. Surgical pathology from the liver biopsy revealed mild steatohepatitis with stage 0-1/4 fibrosis (Fig. 1). On outpatient follow-up, the patient was started on a stricter diet and exercise regimen for weight loss. EUS-guided applications have been increasing over the past decade; today, both endoscopy and echoendoscopy offer tremendous diagnostic information to help guide management in the workup of liver disease.2Samarasena J. Chang K.J. Endo-hepatology: a new paradigm.Endosc Ultrasound. 2018; 7: 219-222Crossref PubMed Scopus (6) Google Scholar In particular, EUS-guided liver biopsy has emerged as a safe and minimally invasive approach and an alternative to a percutaneous technique and now can be paired with EUS-guided real-time elastography and PPG measurement.3Huang J.Y. Samarasena J.B. Tsujino T. et al.EUS-guided portal pressure gradient measurement with a simple novel device: a human pilot study.Gastrointest Endosc. 2017; 85: 996-1001Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,4Shah A. Martinez I.C. Valentin N. et al.Efficacy and safety of endoscopic ultrasound-guided liver biopsies in parenchymal liver diseases: a systematic review and meta-analysis.Am J Gastroenterol. 2018; 113: S565-S566Crossref Google Scholar Here, we demonstrate the safety and technique of EUS-guided PPG measurement in the diagnostic workup of abnormal liver tests. Dr Sharaiha is a consultant for Boston Scientific and Apollo Endosurgery (terminated). All other authors disclosed no financial relationships. https://www.videogie.org/cms/asset/91a9cbf3-9569-4652-812c-a82edde33120/mmc1.mp4Loading ... Download .mp4 (65.17 MB) Help with .mp4 files Video 1“One stop” liver-focused endoscopy: EUS-guided portal pressure gradient measurement technique.

Iatrogenic injury of posterolateral structures during femoral tunneling in anterior cruciate ligament reconstruction: A cadaveric study

ObjectiveCreating Femoral tunnel in Anterior Cruciate Ligament (ACL) reconstruction can be done through some portal. Transportal technique commonly preferred by Orthopedic Surgeon. However, this technique may possess some iatrogenic injury to knee structure especially in the posterolateral during the drilling. This study aim is to describe the most susceptible injured posterolateral structure of the knee during femoral tunneling from trans portal technique Anterior Cruciate Ligament (ACL) reconstruction. MethodsTwenty knees from ten cadavers was examined. Anterior Cruciate Ligament (ACL) reconstruction was simulated using the trans portal technique. Femoral drilling was performed with knee in 120 flexion. The cadaver was dissected to identify the injured posterolateral structure during femoral tunneling. The data collected was anatomy structure and the wound size. ResultsAll Twenty knees were included in the study. 90% of injured structure was iliotibial band. The next most common was plantaris (50%) dan gastrocnemius (45%) muscle. The other was biceps femoris muscle (20%). The least common injury was vastus lateralis (5%). No injury was observed in Lateral Collateral Ligament (LCL), popliteus tendon, and peroneal nerve. ConclusionTransportal technique during femoral drilling in Anterior Cruciate Ligament (ACL) reconstruction does do damage to some of the posterolateral structure. The injury was considered minimal and may not result in function deterioration. There is also no risk to common peroneal nerve.

Anatomical Single-Bundle Transtibial Anterior Cruciate Ligament Reconstruction

Anatomical anterior cruciate ligament (ACL) reconstruction is a reasonable transition from isometric ACL reconstruction to obtain better clinical outcomes, and most authors believe that it can only be performed through the medial portal technique. However, in our clinical practice, we found that anatomical ACL reconstruction can be performed easily and accurately by creating a tibial tunnel, which is accomplished by setting the tibial tunnel with correct angulation to the sagittal plane and tibial axis. Hence, we introduce this special transtibial anatomical ACL reconstruction technique, in which the most critical step is the creation of a shallow tibial tunnel with a proximal projection to the anatomical location of the femoral tunnel. This technique is indicated for primary ACL reconstructions in skeletally mature patients. We believe this Technical Note will give a special view on anatomical ACL reconstruction.

Trauma and femoral tunnel position are the most common failure modes of anterior cruciate ligament reconstruction: a systematic review.

To improve outcomes of anterior cruciate ligament reconstruction (ACLR), it is important to understand the reasons for failure of this procedure. This systematic review was performed to identify current failure modes of ACLR. A systematic search was performed using PubMed, EMBASE, Cochrane, and annual registries for ACLR failures. Studies were included when failure modes were reported (I) of ≥ 10 patients and (II) at a minimum of two-year follow-up.Modes of failure were also compared between different graft types and in femoral tunnel positions. This review included 24 cohort studies and 4 registry-based studies (1 level I, 1 level II, 10 level III, and 16 level IV studies). Overall, a total of 3657 failures were identified. The most common single failure mode of ACLR was new trauma (38%), followed by technical errors (22%), combined causes (i.e. multiple failure mechanisms; 19%), and biological failures (i.e. failure due to infection or laxity without traumatic or technical considerations; 8%). Technical causes also played a contributing role in 17% of all failures. Femoral tunnel malposition was the most common cause of technical failure (63%). When specifically looking at the bone-patellar tendon-bone (BPTB) or hamstring (HT) autografts, trauma was the most common failure mode in both, whereas biological failure was more pronounced in the HT group (4% vs. 22%, respectively). Technical errors were more common following transtibial as compared to anteromedial portal techniques (49% vs. 26%). Trauma is the single leading cause of ACLR failure, followed by technical errors, and combined causes. Technical errors seemed to play a major or contributing role in large part of reported failures, with femoral tunnel malposition being the leading cause of failure. Trauma was also the most common failure mode in both BPTB and HT grafts. Technical errors were a more common failure mode following transtibial than anteromedial portal technique. IV.

Excellence in Research:A Hybrid Transtibial Technique Combines the Strengths of theAnteromedial Portal and Transtibial Approaches: A Prospective Randomized Controlled Trial

Objectives:Improved biomechanical and clinical outcomes have been reported when femoral anterior cruciate ligament (ACL) tunnels are centered on the native footprint. The anteromedial (AM) portal technique achieves improved aperture position when compared to a transtibial (TT) approach but sacrifices technical ease and creates a shorter more acutely angulated tunnel. A hybrid transtibial technique (HTT) technique using medial portal guidance of a flexible transtibial guide wire without the need for knee hyperflexion may combine the strengths of both the AM and TT approaches. The authors hypothesized that this HTT technique would achieve anatomic femoral tunnel apertures similar to the AM technique, but with longer and less angulated femoral tunnels similar to a TT technique.Methods:A prospective randomized controlled trial was implemented where 30 consecutive patients with acute, primary ACL tears were randomized to receive a TT, AM or HTT technique for their reconstruction. A total of 46 patients were assessed for eligibility in the investigation (Figure 1). All patients underwent 3D CT scans of the operative knee 6 weeks postoperatively to characterize tunnel positions. Femoral and tibial tunnel aperture positions and tunnel lengths, as well as the graft bending angle in the sagittal and coronal plane were measured.Results:There were no significant differences between the patient demographics of the three groups. Tibial tunnel lengths and aperture positions were identical between the three groups. The AM portal and HTT techniques achieved identical femoral aperture positions in regards to both height (p=0.75) and depth (p=0.72). On the other hand, compared to the AM portal and HTT techniques, respectively, femoral apertures created by the TT technique were significantly higher (p<0.001 and p<0.001) and shallower (p=0.001 and p<0.001) in the notch. The average femoral tunnel lengths varied significantly between the three groups measuring 35.16 mm, 41.64 mm, and 54.13 mm for the AM, HTT and TT groups, respectively (p<0.001). Lastly, there were no differences between the average coronal (164.0 degrees versus 158.8 degrees, p=0.190) and sagittal (114.0 degrees versus 111.0 degrees, p=0.358) graft bending angles between the TT and HTT groups, respectively. By contrast, compared to the TT and HTT groups, respectively, the graft bending angles created with an AM technique were significantly more acutely angled in the coronal (146.3 degrees, p<0.001, p<0.006) and sagittal (100.5 degrees, p=0.014, p=0.013) planes.Conclusion:The HTT technique achieves femoral aperture positions equally as anatomic as an AM portal technique, but with longer and less acutely oriented grafts similar to a transtibial approach. These advantages will decrease the incidence of graft tunnel mismatch as well as reduce the amount of stress imparted onto the graft by avoiding an acute graft bending angle. As such, this hybrid approach may represent a beneficial combination of both transtibial and AM portal techniques.

Ultrasound-guided anatomical liver resection using a compression technique combined with indocyanine green fluorescence imaging

BackgroundAnatomical resection (AR) is a recommended surgical treatment for hepatocellular carcinoma (HCC). However, the conventional procedure (dye injection) for AR is difficult to reproduce. As an alternative, the tumour-feeding portal pedicle compression technique (finger-compression technique) has been proposed as an easy and reversible procedure. Here, we propose a new method combining indocyanine green (ICG) imaging with the finger-compression technique. MethodsEligible patients were prospectively enrolled to undergo ICG compression (ICG-C) anatomical hepatectomy for HCC. ResultsFifteen patients underwent AR using the ICG-C technique. Overall, the surgical procedures included six segmentectomies, seven subsegmentectomies, and two right posterior sectionectomies. The median tumour size was 5.8 cm (range 2–7 cm). All procedures had an R0 margin. There were no major complications among patients, and minor morbidity occurred in three patients. ConclusionsICG-C is a safe, feasible and effective technique for patients eligible for AR.

Tailored classification of portal vein thrombosis for liver transplantation: Focus on strategies for portal vein inflow reconstruction.

Portal vein thrombosis (PVT) is currently not considered a contraindication for liver transplantation (LT), but diffuse or complicated PVT remains a major surgical challenge. Here, we review the prevalence, natural course and current grading systems of PVT and propose a tailored classification of PVT in the setting of LT. PVT in liver transplant recipients is classified into three types, corresponding to three portal reconstruction strategies: Anatomical, physiological and non-physiological. Type I PVT can be removed via low dissection of the portal vein (PV) or thrombectomy; porto-portal anastomosis is then performed with or without an interposed vascular graft. Physiological reconstruction used for type II PVT includes vascular interposition between mesenteric veins and PV, collateral-PV and splenic vein-PV anastomosis. Non-physiological reconstruction used for type III PVT includes cavoportal hemitransposition, renoportal anastomosis, portal vein arterialization and multivisceral transplantation. All portal reconstruction techniques were reviewed. This tailored classification system stratifies PVT patients by surgical complexity, risk of postoperative complications and long-term survival. We advocate using the tailored classification for PVT grading before LT, which will urge transplant surgeons to make a better preoperative planning and pay more attention to all potential strategies for portal reconstruction. Further verification in a large-sample cohort study is needed.

A comparison of the clinical effects of arthroscopic treatment for popliteal cyst between techniques using one posteromedial portal and two posteromedial portals

There is a lack of research comparing the clinical effects of arthroscopic treatment of popliteal cysts between the one posteromedial portal (OPP) technique and the two posteromedial portals (TPP) technique. The aim of this study was to evaluate and compare the clinical efficacy of arthroscopic treatment for popliteal cysts between the 2 techniques.Patients with symptomatic popliteal cysts after surgery were retrospectively invited to participate in this study. They received arthroscopy treatment via the OPP technique or the TPP technique. At the final follow-up, the Rauschning and Lindgren criteria and the Lysholm score were used for clinical evaluation. Moreover, magnetic resonance imaging was performed to detect the recurrence of cysts postoperatively.Finally, 53 patients with symptomatic popliteal cysts were included in this study, including 25 in the OPP group and 28 in the TPP group. The operation time of the TPP group was significantly longer than that of the OPP group (P < .001). In the OPP group, the cysts disappeared in 17 patients and reduced in size in 8 patients. In the TPP group, the cysts disappeared in 23 patients and reduced in size in 5 patients. According to the Rauschning and Lindgren classification, the recurrence rate was significantly lower in the TPP group (0%) than in the OPP group (4%) (P = .03). In addition, there was no significant difference in the Lysholm score between the OPP group and the TPP group (P = .77).TPP technique is more effective and superior than OPP technique for the treatment of popliteal cysts.

Physeal-sparing posteromedial portal approach reduced distance between guide pin and neurovascular structures

To compare a femoral physeal sparing anterior cruciate ligament (ACL) reconstruction technique utilizing a posteromedial portal to traditional transphyseal techniques with regards to anatomic tunnel positioning and proximity to important neurovascular structures. Eight cadaveric knees were obtained for the study. Femoral tunnel guide pins were placed utilizing four different techniques: accessory anterior medial portal, posteromedial portal, trans-tibial, and figure-4 methods. The knees were then dissected and the following measurements taken: distance of each pin to the saphenous and peroneal nerve, popliteus tendon, neurovascular bundle, femoral ACL footprint and articular cartilage, and the angle of the guide pin entering the lateral femoral condyle. Fluoroscopic imaging was taken to determine the disruption of the physeal scar. Posteromedial portal guide pin was significantly closer to the neurovascular bundle, popliteal tendon and saphenous nerve when compared to the other 3 techniques, but was further from the peroneal nerve. It also had the smallest distance from the anatomic footprint of the ACL, and the largest angle to the lateral femoral condyle. The posteromedial portal guide pin had similar distance from the articular cartilage as the accessory anterior medial portal and figure-4 guide pin, with the trans-tibial guide pin being the farthest. The posteromedial portal guide pin failed to disrupt the physeal scar in all specimens, while the other three techniques consistently violated the physeal scar. The posteromedial portal technique offers an appropriate method for anatomic ACL reconstruction while protecting the distal femoral physis from injury. Care needs to be taken with this technique as it comes in closer proximity to some of the important neurovascular structures. This study indicates that posteromedial portal technique is a less technically challenging approach for physeal-sparing ACL repair with special attention required for the protection of neurovascular bundle from potential injury.

The Role of Hip Arthroscopy in the Management of Acute Arthritis of Hip

Septic arthritis of hip is an orthopaedic emergency requiring early diagnosis and prompt surgical treatment to avoid grave complications like avascular necrosis and chondrolysis and post-infectious arthrosis.This is a retrospective review of 9 patients who underwent hip arthroscopy for suspected septic arthritis of hip from 2012 to 2018. Medical charts were reviewed to determine the efficacy of the use of hip arthroscopy in the diagnosis and treatment of acute hip arthritis.The age of patients ranged from 9 to 82. The mean follow-up was 29 months (1 to 49). All presented with hip pain and effusion in imaging by CT scan or ultrasonography. Fever was present in 5 out of 9 patients. Hip arthroscopy with 2 portals technique and joint lavage +/- debridement was done. Two patients had whitish suspension in the joint fluid and pathology confirmed pseudogout of hip. The remaining 7 patients were diagnosed and treated as septic hip arthritis. Only 3 had positive culture, probably related to the prior use of antibiotics. All except one responds well to arthroscopic debridement and lavage with infection eradicated, good hip motion and hip function. One patient of delayed treatment (2 weeks after onset of hip pain) had ongoing infection, requiring further arthrotomy and Girdlestone operation for uncontrolled hip infection with intramuscular abscess of vastus lateralis.Hip arthroscopy is a useful diagnostic tool in acute hip arthritis. Besides septic arthritis, monoarticular attack of psuedogout is an important differential diagnosis of acute hip pain in elderly. Early hip arthroscopy can result in rapid postoperative recovery. Arthroscopic lavage and debridement is safe and a good alternative to open arthrotomy in hip septic arthritis.

Techniques for Femoral Socket Creation in ACL Reconstruction.

Anterior cruciate ligament (ACL) injury is common and affects a wide variety of individuals. An ACL reconstruction is the treatment of choice for patients with subjective and objective symptoms of instability and is of particular importance to cutting or pivoting athletes. With many variables involved in ACL reconstruction, femoral tunnel placement has been found to affect clinical outcomes with nonanatomic placement being identified as the most common technical error. Traditionally the femoral tunnel was created through the tibial tunnel or transtibial with the use of a guide and a rigid reaming system. Because of proximal, nonanatomic tunnel placement using the transtibial technique, the use of the anteromedial portal and outside-in drilling techniques has allowed placement of the tunnel over the femoral footprint. In this paper, we discuss the difference between the 3 techniques and the advantages and disadvantages of each. The authors then explore the clinical differences and outcomes in techniques by reviewing the relevant literature.

Iatrogenic Injury to the Posterolateral Knee During Anterior Cruciate Ligament Reconstruction with Anteromedial Portal Technique

BACKGROUND: Femoral tunnel reaming through anteromedial portal, also known as transportal technique, allows for anatomic femoral tunnel placement in restoring anterior cruciate ligament (ACL) kinematics. This procedure may cause iatrogenic injury to the posterolateral structures of the knee.&#x0D; PURPOSE: This study aims to assess the risk of posterolateral structure injury in ACL reconstruction using transportal technique.&#x0D; METHODS: ACL reconstruction using transportal technique was performed in 20 patients. Clinical and radiological examination was performed preoperatively and 1 month postoperatively. Clinical examination included any pain or paresthesia on posterolateral area of the knee, varus alignment of the knee, abnormal gait, and specific tests for posterolateral stability. Radiological evaluation was plain radiography and stress radiography for posterolateral stability, and magnetic resonance imaging (MRI) for assessing structural damage.&#x0D; RESULTS: Post-operative evaluation showed pain in posterolateral area in five patients, numbness on posterolateral knee in one patient, both pain and numbness in two patients and lateral gastrocnemius muscle injury on MRI in six patients. We did not find varus knee alignment and abnormal gait. Specific tests were negative in post-operative evaluation. Post-operative radiographic imaging did not show the sign of lateral widening.&#x0D; CONCLUSION: Femoral tunnel drilling using transportal technique in ACL reconstruction is safe even it might risk to damage lateral gastrocnemius muscle, according to clinical and MRI findings.

Anteromedial positioning of the femoral tunnel in anterior cruciate ligament reconstruction is the best option to avoid revision: a single surgeon registry

PurposeThe aim of the study is to compare the risk of revision of single-bundle hamstring anterior cruciate ligament (ACL) reconstruction between the anteromedial, transtibial and outside-in techniques.MethodsThis cohort study was based on data from a single surgeon’s registry. Patients who underwent primary single-bundle ACL reconstruction with hamstring tendon using the anteromedial portal, transtibial and outside-in technique, operated between 1 November 2003 to 31 December 2016, were eligible for inclusion. A minimum follow-up of 2 years was used, and the end-point of the study was revision surgery.ResultsThe total number of registered surgeries identified was 665; 109 were excluded, and 556 was the final sample. The overall revision rate was 8.7%. The transtibial technique presented 14/154 [9.9%] of revisions, the transportal 11/96 [11.4%] and the outside-in 22/306 [7.2%]. Separating the outside-in group into central outside-in and anteromedial (AM) outside-in, 18/219 [8.2%] was found for the central outside-in and 4/87 [4.5%] for the AM outside-in technique. Statistical evaluation of the first comparison (transtibial vs. transportal vs. outside-in) obtained p = (n.s.) The second comparison (transtibial vs. central transportal vs. central outside-in vs. AM outside-in, p = (n.s). Placement was also evaluated: high anteromedial placement (transtibial) vs. central (transportal and central outside-in technique) vs. AM placement (AM outside-in). The high AM placement presented 14/154 [9.9%] of revision, the central placement 29/315 [9.2%] and the AM placement 4/87 [4.5%], p = (n.s.) The AM placement was also compared with the other placements (high and central AM), p = (n.s.)ConclusionBased on the registry of a single surgeon during 14 years of ACL reconstruction, the placement of the femoral tunnel in the high anteromedial region was associated with a rupture rate of 9.9%, central placement with 9.2% and anteromedial placement with 4.5%.

Evolution of Surgical Management of Colorectal Liver Metastasis

AbstractThe treatment of colorectal liver metastasis (CRLM) has progressed markedly in the past decades. Main contributions stem from improvement in surgical approach and applications of chemotherapy. The availability of several perioperative and surgical techniques, including portal vein embolization, ablation techniques, and two-stage hepatectomies, has expanded surgical indications. In addition, preoperative imaging methods have contributed to these advances.In patients with high oncological risk of recurrence, or initially unresectable CRLM, highly individualized treatment regimens are becoming more widely utilized. These patients should be evaluated for surgical resection after several cycles of chemotherapy given the survival benefit afforded by liver resection for CRLM. Several biomarkers, including RAS mutation, BRAF mutation, and microsatellite stability, have become essential in guiding therapy. Immunotherapy has recently been highlighted, especially for cases of microsatellite instability. Looking forward, biomarkers will likely to continue to guide individualized treatment patterns.Liver transplantation as an option for patients with unresectable CRLM may boast comparable outcomes to patients with primary liver tumors, but it remains controversial considering the limited supply of donor livers.Management of CRLM requires the complex decision making process common to contemporary tumor board discussions, and a multidisciplinary approach likely figures into future directions of management for CRLM.

3:36 PM Abstract No. 76 Minimizing the pain of local anesthesia in interventional radiology with an anesthetic portal technique

3:36 PM Abstract No. 76 Minimizing the pain of local anesthesia in interventional radiology with an anesthetic portal technique

Similar functional outcome using single anterior portal and standard two portals technique in recurrent dislocation of shoulder

PurposeRecurrent dislocation of shoulder (RDS) is a common injury in high demand professionals, like athletes and military personnel. The treatment for the patients with Bankart lesion is the arthroscopic repair. This present study compares the outcomes of two different techniques of arthroscopic Bankart repair i.e. a standard two anterior portals technique and a single anterior portal technique in patients with RDS. MethodsPatients with traumatic RDS met the inclusion criteria were managed with Bankart repair using either two anterior portals (Group A) or a single anterior portal (Group B) technique. Patients were evaluated before the intervention and at the mean follow-up of approximately two years using Rowe score, Oxford shoulder score and Tegner activity scale. ResultsThe mean age of the patients in Groups A (n = 34) and B (n = 37) was 29.64 years and 29.05 years respectively (p = 0.66). The dominant shoulder was involved in 27 patients in Group A and 22 patients in Group B (p = 0.069). The operative time in Group A and B was 68.52 min and 46.35 min, respectively (p < 0.001). The complications at follow-up, the mean Rowe score and Oxford score improved significantly in both groups compared with the pre-operative values. However, the final outcome scores were not significantly different between the both groups. The median Tegner's score preoperatively and at follow-up was 7 and 6, respectively in Groups A and B. ConclusionsSingle anterior portal technique is an effective treatment modality, yielding a similar outcome as two anterior portals technique in the management of RDS.

Robot-assisted Lobectomy under Port-only Mode with Artificial Pneumothorax

背景与目的达芬奇机器人手术操作系统目前在胸外科得到了广泛的应用，国内不同中心采用的建立通道方式及操作流程，不同辅助操作孔多采用小切口的方式。方法基于大量临床实践的基础上，我们在实践中总结国内、外经验，并结合国人体型特点，对机器人辅助肺叶切除术的切口及操作流程进行了改进并实践出一套更加简化易行的手术方法。结果全孔道（port-only）人工气胸下机器人辅助肺叶切除术在术中解剖安全性，止血效果和伤口美观性方面，都有进一步的提升。结论本研究对全孔道人工气胸机器人辅助肺叶切除的流程加以优化，以期为肺癌患者更好地服务。

Comparison of Transtibial and Anteromedial Portal Techniques Used in Anterior Cruciate Ligament Repair Using Autogenous Hamstring Tendon Graft

Aim: The aim of this study was to investigate the effects of transtibial (TT) and anteromedial portal (AMP) techniques used in anterior cruciate ligament repair on knee joint function after anterior cruciate ligament reconstruction.Material and Methods: Sixty patients who were surgically treated in our clinic for anterior cruciate ligament tear were included in the study. Thirty patients underwent TT technique and 30 patients underwent AMP. Functional evaluations were performed according to Lysholm, International Knee Documentation Committee (IKDC) and Tegner scoring preop and postop. The angle between the femoral tunnel and the distal joint face was measured in postoperative Anteroposterior and Lateral knee graphs and its effect on the knee joint functional outcome was examined.Results: Eighty percent of the patients included in the study were male (n=47) and 20% were female (n=13). The gender distribution according to the groups was homogeneous (p=0.476). The mean age of the subjects was 32.75±8.81 (16-53) years. The postoperative Lysholm score was significantly higher in the AMP group than in the TT group (p&amp;lt;0.001). The postoperative Tegner score was significantly higher in the AMP group than in the TT group (p&amp;lt;0.001). Mean femoral tunnel obliquity was 59.3° in the TT group and 41.4° in the AMP group.Conclusion: It is thought that oblique femoral tunnel placement is more beneficial for the rotational stability of anterior cruciate ligament. In our study, we think that AMP technique is more beneficial than femoral obliquity in terms of functional outcome.

Revision of Failed-Posterior Cruciate Ligament (PCL) Reconstruction Due To Tibial Tunnel Misplacement: A Case Report

Objectives:Posterior cruciate ligament (PCL) reconstruction failure is a rare condition found. The failure caused by some factors, including improper graft tunnel placement. The proper tibial tunnel placement in PCL reconstruction is still controversial. To have an anatomical tunnel is essential to decrease the risk of failure. The use of PCL jig only to guide the direction of the tibial tunnel may not always give good results.Case presentation:We report a case of a 29-year-old male with a total rupture of ACL and PCL that underwent reconstruction for both ligaments. We found the failure of the PCL graft 2 years after the surgery was related to the tibial tunnel placement which was placed not in proper anatomical site. We performed revision PCL surgery with a transseptal portal technique to ensure the tibial tunnel is placed inappropriate position.Result:The cause of failure was associated with the miss position of the tibial tunnel. The tibial tunnel performed in previous surgery was too anterior than the anatomical footprint. This condition might be caused by a surgical technique that depending only on PCL jig to guide the tibial tunnel direction and location. We performed a transseptal portal technique to get better visualization on the posterior aspect of the knee to achieve the proper direction of the tibial tunnel.Conclusion:The use of PCL jig as the only tool for guiding tibial tunneling should be avoided. An additional tool such as a transseptal portal is required to ensure the proper anatomical tibial tunnel to achieve good PCL graft placement.