Posterior Dissection Research Articles

Biomechanical evaluation of a novel dynamic posterior cruciate ligament brace

BackgroundUse of a rigid brace or cast immobilization is recommended in conservative treatment or postoperative rehabilitation after a posterior cruciate ligament injury. To prevent the loss of knee joint function and muscle activity often associated with this, a flexible knee brace has been developed that allows an adjustable anteriorly directed force to be applied to the calf in order to prevent posterior tibial translation. The purpose of this biomechanical study was to evaluate the impact of this novel dynamic brace on posterior tibial translation after posterior cruciate ligament injury and reconstruction. MethodsA Telos stress device was used to provoke posterior tibial translation in seven human lower limb specimens, and stress radiographs were taken at 90° of knee flexion. Posterior tibial translation was measured in the native knees with an intact posterior cruciate ligament; after arthroscopic posterior cruciate ligament dissection with and without a brace; and after posterior cruciate ligament reconstruction with and without a brace. The force applied with the brace was measured using a pressure sensor. FindingsPosterior tibial translation was significantly reduced (P=0.032) after application of the brace with an anteriorly directed force of 50N to the knees with the dissected posterior cruciate ligament. The brace also significantly reduced posterior tibial translation after posterior cruciate ligament reconstruction in comparison with reconstructed knees without a brace (P=0.005). InterpretationPosterior tibial translation was reduced to physiological values using this dynamic brace system that allows an anteriorly directed force to be applied to the calf.

Abstract TP217: Different Features of Anterior and Posterior Circulation Dissections

Introduction: The features of vascular images and risk factors might be different according to the location of the cervicocerebral artery dissection. Hypothesis: We investigate whether the risk factors, neuroimaging features, and imaging outcomes differ according to the dissection site (anterior vs. posterior circulation). Methods: Consecutive patients who presented with ischemic symptoms and underwent brain vascular imaging within seven days after the onset of symptoms were enrolled. Demographic characteristics, putative risk factors, imaging findings, and types of antithrombotic medication were assessed between anterior circulation dissection (ACD) and posterior circulation dissection (PCD). The baseline and follow-up vascular images (6 months or 1 year after the onset of symptoms) were compared to determine the prognostic difference in the reverse of the lesion. Results: A total of 117 patients (n=32 with ACD and n=85 with PCD) were eligible for these analysis. The median delay from symptom onset to baseline vascular imaging was a day (IQR 1, 2). Patients with PCD were older (OR=1.5 by increasing 10 years old [1.02-2.03], p=0.038) and had a dissection associated with exercise or neck manipulation more frequently (OR=4.8 [1.2-18.1], p=0.019) compared to patients with ACD. Arterial stenosis or occlusion was the most common imaging feature (94% in ACD vs. 86% in PCD, p= 0.345). Aneurysm or pseudoaneurysm was identified in 9.4% of ACD and 24.7% of PCD (p=0.067). Among patients with PCD, vertebral artery was the most common lesion site (65% [53-74%]). The complete reverse on the follow-up images at the 6 months or 1 year was identified in 9 patients with ACD and 11 patients with PCD (45% vs. 22%, p=0.054). Neither anticoagulation nor antiplatelet demonstrated significant differences between the frequency of the complete reverse on the follow-up vascular images in patients with ACD and PCD (33% vs. 21%, p=0.613 for anticoagulation; 44% vs. 23%, p=0.087 for antiplatelet). Conclusions: These results substantiate the difference in the risk factors and radiologic features according to the dissection site. There was no difference in efficacy of antiplatelet and anticoagulant drugs at complete reverse of the lesion after cervicocerebral artery dissection.

Influence of Intraocular Lens Material and Eye Axial Length on Posterior Capsule Opacification Dynamic Rate and Frequency

Purpose: To evaluate posterior capsule opacification (PCO) formation dynamic rate and frequency in artificial eyes with myopia in different terms after cataract extraction and it’s relation with IOL material. Patients and methods. An evaluation of PCO formation dynamic rate and frequency was done by using a retrospective analysis of YAG-laser assist posterior capsule dissections in different terms after cataract extraction on 45640 eyes of 43520 patients with emmetropia and myopia without concomitant pathology. The mean patient’s age was 73±7 years and the least follow-up after hacoemulsification was 5 years. All eyes were divided on two groups. The first group included 25339 eyes where a hydrophilic IOL was implanted; the second group included 20301 eyes where a hydrophobic IOL was implanted. Results. At the first group the YAG-laser assist posterior capsule dissection was done on 2128 (8,4%) eyes. It was shown a proportional influence of axial length on PCO frequency but more rapidly the PCO rate increased between 26 to 28 mm and then this parameter had stabilization. The PCO dynamic rate had a normal statistical corresponding in the group with maximum at third postoperative year. At the second group YAG-laser assist posterior capsule dissection was done on 244 (1,2%) eyes. It was shown a proportional influence of axial length on PCO frequency too. But increasing of axial length more than 28 mm increased PCO rate correspondingly that differ the second group from the first. The PCO dynamic rate had an inversely proportional character in the group. Comparing the PCO frequency in both groups showed that hydrophobic material has less PCO rate with any axial length and every time of follow-up. Conclusion. An IOL’s material plays an important role in PCO formation and PCO formation dynamic rate. Hydrophobic material has a statistically significant less PCO frequency through five-year follow-up in eyes with myopia and emmetropia. The PCO dynamic rate strongly differ between groups with a normal statistical corresponding in group 1 and inversely proportional in group 2.

The split portal: Description of a new accessory posterior portal for arthroscopic shoulder instability procedures.

Open approach to the posterior shoulder during bone block for posterior shoulder instability is challenging. Anatomical study was performed to identify landmarks of a portal, avoiding soft tissue damage, between the infraspinatus (IS) and teres minor (TM) muscles and distant from the supra-scapular nerve (SSN) for arthroscopic shoulder bone block. Eight fresh-frozen cadaveric shoulder specimens were used. The arthroscope was introduced through the soft point (SP). A guide wire was placed through the SP, in the rotator interval direction. A posterior open dissection exposed the split between the IS and TM. A new guide wire was placed into the split, parallel to the first wire, to locate the new posterior arthroscopic approach. Ten distances were measured to define the safe position. The mean values were: SP to split IS-TM: 2 ± 0.2 (2-2.8); spinal bone to split IS-TM: 5 ± 0.5 (3-6.2); split IS-TM to posterior glenoid 6 o'clock: 1.3 ± 0.3 (0.6-1.6), 9 o'clock: 1.5 ± 0.3 (1-1.9), and 12 o'clock: 2 ± 0.1 (2.1-2.4); SSN to posterior glenoid 6 o'clock: 2.4 ± 0.2 (2.1-2.6), 9 o'clock: 1.7 ± 0.1 (1.5-1.8), and 12 o'clock: 1.5 ± 0.3 (1.2-2.1); and SSN to split IS-TM: 2 ± 0.3 (1.2-2.1). This preliminary anatomical study described a posterior arthroscopic portal located 2 cm under the SP, parallel to the SP portal direction, and finishing between 7 and 8 o'clock at the posterior rim of the glenoid. For arthroscopic shoulder bone block, this portal can avoid muscle and SSN lesions.

Os Odontoideum Mimicking Acute Odontoid Peg Fracture

The atlantoaxial complex is a common site for cervical spine injuries, of which fractures of the axis (C2), occur most frequently. Over half of these fractures involve the odontoid process. Numerous developmental anomalies of the axis, although rare, can also occur and may simulate trauma. Specifically, os odontoideum is a cranial-vertebral junction anomaly in which the odontoid remains separate from the body of the axis as an independent ossicle. We report a case of a 53-year-old incarcerated male who was found by his five cellmates hanging partially suspended by a bed sheet. Emergency personnel re-established a pulse for a short time, and the patient was transferred to the hospital. Imaging of the cervical spine pointed to an avulsion fracture of the odontoid process of the axis, raising the possibility of trauma and foul play. Postmortem lateral radiographs revealed a smooth ossicle with a circumferential cortical rim superior to the axis, and a posterior neck dissection failed to reveal evidence of an acute injury. Contrary to the diagnosis of an isolated odontoid fracture, this is a case of os odontoideum. This case emphasizes the importance of a thorough dissection with direct visualization, accompanied by a complete investigation and radiographs. An overview of the development of the axis is discussed, including descriptions of various anomalies of the odontoid that may be encountered during postmortem cervical spine examination. Failure of the forensic pathologist to recognize the developmental anomalies of the axis could lead to improper certification of death, resulting in devastating medicolegal consequences.

Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment

BackgroundUse of robot-assisted radical prostatectomy (RARP) for prostate cancer is increasing. Structured surgical training and objective assessment are critical for outcomes. ObjectiveTo develop and validate a modular training and assessment pathway via Healthcare Failure Mode and Effect Analysis (HFMEA) for trainees undertaking RARP and evaluate learning curves (LCs) for procedural steps. Design, setting, and participantsThis multi-institutional (Europe, Australia, and United States) observational prospective study used HFMEA to identify the high-risk steps of RARP. A specialist focus group enabled validation. Fifteen trainees who underwent European Association of Urology robotic surgery curriculum training performed RARP and were assessed by mentors using the tool developed. Results produced LCs for each step. A plateau above score 4 indicated competence. Outcome measurements and statistical analysisWe used a modular training and assessment tool (RARP Assessment Score) to evaluate technical skills. LCs were constructed. Multivariable Kruskal-Wallis, Mann-Whitney U, and κ coefficient analyses were used. Results and limitationsFive surgeons were observed for 42 console hours to map steps of RARP. HFMEA identified 84 failure modes and 46 potential causes with a hazard score ≥8. Content validation created the RARP Assessment Score: 17 stages and 41 steps. The RARP Assessment Score was acceptable (56.67%), feasible (96.67%), and had educational impact (100%). Fifteen robotic surgery trainees were assessed for 8 mo. In 426 RARP cases (range: 4–79), all procedural steps were attempted by trainees. Trainees were assessed with the RARP Assessment Score by their expert mentors, and LCs for individual steps were plotted. LCs demonstrated plateaus for anterior bladder neck transection (16 cases), posterior bladder neck transection (18 cases), posterior dissection (9 cases), dissection of prostatic pedicle and seminal vesicles (15 cases), and anastomosis (17 cases). Other steps did not plateau during data collection. ConclusionsThe RARP Assessment Score based on HFMEA methodology identified critical steps for focused RARP training and assessed surgeons. LCs demonstrate the experience necessary to reach a level of competence in technical skills to protect patients. Patient summaryWe developed a safety and assessment tool to gauge the technical skills of surgeons performing robot-assisted radical prostatectomy. Improvement was monitored, and measures of progress can be used in future to guide mentors when training surgeons to operate safely.

Initial retrocolic endoscopic tunnel approach (IRETA) for complete mesocolic excision (CME) with central vascular ligation (CVL) for right colonic cancers: technique and pathological radicality.

The concept of complete mesocolic excision (CME) with central vascular ligation (CVL) for treatment of right colon cancer evolved over last one decade. It decreases local recurrences and improves the survival rates. We describe our novel technique which involves first posterior sharp dissection between planes of parietal and visceral fascia of mesocolon followed by ligation of ileocolic, right colic and middle colic pedicles at their origin. We highlight the technical variations with various techniques and advantages over conventional medial to lateral approach in current study. The outcomes were measured in terms of technical feasibility, short-term outcomes and pathological radicality of current laparoscopic technique (IRETA) for CME with CVL. Two hundred twelve patients (163 males) who underwent laparoscopic CME for right colon cancer over the period of January 2009 to December 2013 were analysed via prospectively maintained database. 97.16 % of patients (n = 206) underwent laparoscopic CME while six patients required open conversion. Mean operative time was 142 ± 28.4 min with median hospital stay of 5 days (range 4-11). The median count of lymph node harvested were 24 (range 10-42). The complete mesocolic excision plane was achieved in 93.8 % patients. 84.4 % (n = 179) of our patients were having (T3, N+) disease on pathological examination. The overall morbidity (<30 days) was 9.9 %. Laparoscopic initial retrocolic endoscopic tunnel approach (IRETA) for CME with CVL in right colonic cancers is safe, simpler and feasible laparoscopic approach with minimal complications. Creation of retro colic tunnel is key highlight of IRETA approach. This approach becomes especially useful in patients with late presentations where complete mesocolic excision remains essential to enhance oncological radicality as per evidence available.

Robotic-assisted laparoscopic prostatectomy: An update on functional and oncologic outcomes, techniques, and advancements in technology.

The robotic platform has revolutionized the management of prostate cancer over the last 15 years. Several techniques have been developed to improve functional and oncologic outcomes, including meticulous apical and posterior dissection, nerve sparing techniques, bladder neck and urethral length sparing, and anastomotic reconstruction. Future developments involving novel single-site, robotic technology will undoubtedly further the field of minimally invasive urology. These topics are reviewed within this article.

Investigation of bleeding focus in the intracranial vertebral artery with the use of posterior neck dissection method in traumatic basal subarachnoid hemorrhage

Traumatic basal subarachnoid hemorrhage caused by minor blunt trauma to the head or neck can lead to rapid collapse and death. The vertebral arteries are the vessels most commonly involved in such cases, but it is very difficult to find the bleeding focus in the vertebral arteries in routine autopsy because of the location of these vessels. Using the posterior neck dissection method, which is relatively easy and avoids artificial damage to the intracranial portion of the vertebral arteries, authors have identified tear sites in the intracranial artery in four out of five consecutive traumatic basal subarachnoid hemorrhage cases. In this report we show that this new method is useful for cases of traumatic basal subarachnoid hemorrhage.

Subarachnoid hemorrhage then thrombosis of posterior inferior cerebellar artery dissection: is early surgical exploration warranted?

The natural history of spontaneous cerebral artery dissection and thrombosis remains uncertain. Concurrent subarachnoid hemorrhage further complicates the therapeutic approach. Thus the best strategy for managing patients with acute vessel...

Endoscopy Assisted Oncoplastic Breast Surgery (EAOBS).

Endoscopic oncoplastic breast surgery represents a minimal invasive approach with the aim of both removing cancer safely and also restoring the breast image. It has less noticeable scar, excellent cosmetic outcomes, high patient satisfaction rate and recently reported relatively long term safety. Operative techniques for both endoscopic breast conserving surgery and endoscopic nipple/areola/skin sparing mastectomy have been described in detail. Two different working planes in which one of them is subcutaneous and the other one is sub-mammary planes are being used during the surgery. Surgical techniqe needs some instruments such as endoscopic retractor, light guided specific mammary retractor, wound protector and bipolar scissor. Endoscopic breast retractors provide magnified visualization and extensive posterior dissection facility. Tunneling method and hydrodissection simplify the technique in the subcutaneous field. Oncoplastic reconstruction techniques are also applied after the tumor resection by endoscopic method. Complication rates of endoscopic breast surgery are similar to open breast surgery rates. Quite succesful local recurrence, distant metastasis and overall survival rates have been declared. However it looks reasonable to wait for the results with longer follow-up before having a judgement about oncologic efficiency and safety of the endoscopic breast cancer surgery.

MP22-05 EVALUATION OF TECHNICAL LEARNING-CURVES FOR ROBOT ASSISTED RADICAL PROSTATECTOMY - A MULTI-INSTITUTIONAL STUDY

You have accessJournal of UrologyTechnology & Instruments: Surgical Education & Skills Assessment I1 Apr 2015MP22-05 EVALUATION OF TECHNICAL LEARNING-CURVES FOR ROBOT ASSISTED RADICAL PROSTATECTOMY - A MULTI-INSTITUTIONAL STUDY Catherine Lovegrove, Giacomo Novara, Khurshid Guru, Alex Mottrie, Ben Challacombe, Johar Raza, Henk Van der Poel, James Peabody, Rick Popert, Prokar Dasgupta, and Kamran Ahmed Catherine LovegroveCatherine Lovegrove More articles by this author , Giacomo NovaraGiacomo Novara More articles by this author , Khurshid GuruKhurshid Guru More articles by this author , Alex MottrieAlex Mottrie More articles by this author , Ben ChallacombeBen Challacombe More articles by this author , Johar RazaJohar Raza More articles by this author , Henk Van der PoelHenk Van der Poel More articles by this author , James PeabodyJames Peabody More articles by this author , Rick PopertRick Popert More articles by this author , Prokar DasguptaProkar Dasgupta More articles by this author , and Kamran AhmedKamran Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1017AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Use of robot-assisted radical prostatectomy (RARP) has become the current standard of care. Surgical training and its—assessment are critical in assuring optimal outcomes after robot-assisted approach towards prostatectomy. Learning curves can be used to identify learning needs and evaluate the success of training methods to ensure efficient use of resources in helping trainee surgeons achieve competence. This study aims to evaluate the technical skills of trainees by constructing learning curves for individual steps of RARP. METHODS This multi-institutional, observational, prospective study used a validated assessment score designed to examine the technical skills required for the most hazardous steps of RARP. The RARP Assessment Score was distributed to 15 trainees who performed numerous RARP cases and were scored by their mentors. Results were analysed relative to RARP experience to examine learning—curves for each step. RESULTS 15 trainees were assessed for 8 months. They participated in 426 RARP cases (Range 4–79) and, all 17 procedural steps were attempted. Of reported data, the majority of cases were T stage 2 (40.3%), N stage 0 (59.9%) and “Intermediate” D'Amico risk (36.1%). Learning curves derived demonstrated several findings. Of note were the plateaus for Anterior Bladder Neck Transection (16 cases), Posterior Bladder Neck Transection (18 cases), Posterior Dissection (9 cases), Dissection of Prostatic Pedicle and Seminal Vesicles (15 cases) and Anastomosis (17 cases). For the rest of the steps the LC did not plateau for the data collection period (e.g. Expose Prostatic Apex and Endopelvic Fascia; 31 cases, Stitching and Division of Dorsal Venous Plexus; 32 cases). CONCLUSIONS RARP Assessment Score based on HFMEA methodology identified critical hazardous steps specific to RARP and was used to assess and evaluate surgeons while performing RARP. The learning curves derived demonstrate the experience necessary to reach a level of competence in essential technical skills required to protect patient safety. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e242-e243 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Catherine Lovegrove More articles by this author Giacomo Novara More articles by this author Khurshid Guru More articles by this author Alex Mottrie More articles by this author Ben Challacombe More articles by this author Johar Raza More articles by this author Henk Van der Poel More articles by this author James Peabody More articles by this author Rick Popert More articles by this author Prokar Dasgupta More articles by this author Kamran Ahmed More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Laparoscopic sacrocolpopexy: Demonstration of a nerve-sparing technique

Laparoscopic sacrocolpopexy is a well-established technique to treat apical vaginal prolapse. De novo micturition disorders, pelvic pain, and defecation disorders have been reported and may be due to intraoperative compromise of the superior hypogastric plexus. The video demonstrates our technique for nerve-sparing laparoscopic sacrocolpopexy. The patient is a 62-year-old woman with symptomatic stage III posthysterectomy vaginal vault prolapse. Key steps of the procedure are opening the peritoneum at the level of the promontory, identification of the fibers of the superior hypogastric plexus, deep anterior and posterior dissection with attachment of the mesh to the vagina, displacement of the nerve fibers to the left side during suturing of the mesh to the longitudinal ligament, and complete peritonealization. This technique of the identification and protection of relevant nerve structures appears to be reproducible and can be considered by surgeons who perform laparoscopic sacrocolpopexy.

Outcomes of Robot-Assisted Laparoscopic Prostatectomy with a Posterior Approach to the Seminal Vesicle in 300 Patients.

Background. The goal of this study was to analyze the perioperative outcomes of robot-assisted laparoscopic radical prostatectomies (RALPs) performed at our center. Methodology. We retrospectively reviewed 300 consecutive patients with clinically localized prostate cancer who underwent RALP with a posterior dissection approach to the seminal vesicle between May 2011 and November 2013. The mean patient age was 67.2 ± 5.5 years (range: 41–78 years), and the mean prostate-specific antigen (PSA) concentration, at diagnosis of prostate cancer, was 9.16 ± 6.50 ng/mL (range: 2.20–55.31 ng/mL). Results. The median duration of robotic surgery was 160 min (mean: 165 ± 40 min; range: 75–345 min). Median estimated blood loss, including that in urine, was 200 mL (mean: 277 ± 324 mL; range: 4–3250 mL). Intraoperative and immediate postoperative complications occurred in 3.0% of patients; 4 patients required allogeneic blood transfusion. As a measure of patient continence, 82.4% did not use more than 1 absorbent pad in 24 h, at 6 months postoperatively. Conclusion. RALP with an initial posterior dissection to the seminal vesicle was a safe and efficient method for controlling prostate cancer, even in these initial cases.

A prospective video-controlled study of genito-urinary disorders in 35 consecutive laparoscopic TMEs for rectal cancer

Genito-urinary disorders (GUD) for radical rectal cancer surgery range from 10 to 30%. In this study, primary endpoint is to prospectively assess their incidence in patients undergoing Laparoscopic Total Mesorectal Excision (LTME) without neoadjuvant chemo-radiation (NCR). Secondary endpoint is to detect the potential lesion site evaluating video-recordings of surgery. A study of 35 consecutive patients treated by LTME for extra-peritoneal rectal cancer not subjected to NCR, M:F = 23:12, median age 70, was evaluated preoperatively by Uroflowmetry and US postvoid residual urine measurement (PVR), International Prostatic Symptoms Score (IPSS), and International Consultation on Incontinence Modular Questionnaire (ICIQ) at 1 and 9 months post-operatively. Evaluation of sexual function was carried out by International Index of Erectile Function (IIEF) in males. Data were analyzed performing Fisher and paired samples t tests. Surgical videos of patients affected by GUD were reviewed to identify lesion sites. Urinary function:IPSS average score: baseline 6.03 ± 5.51, 8.93 ± 6.42 (p = .005) at 1 month, and 7.26 ± 5.55 (p = .041) at 9 months. ICIQ baseline 2.67 ± 5.42, 4.27 ± 6.19 (p = NS) at 1 month, and 3.63 ± 5.23 (p = NS) at 9 months. Maximum urine flow rate baseline 15.95 ± 4.78 ml/s, 14.23 ± 5.27 after 1 month (p = .041), and 15.22 ± 4.01 after 9 months (p = NS). Mean urine flow rate baseline 9.15 ± 2.96 ml/s, 7.99 ± 4.12 ml/s at 1 month (p = .044), and 8.54 ± 4.19 ml/s at 9 months (p = NS). PVR baseline 59.62 ± 54.49, 64.59 ± 58.71 (p = NS) at 1 month, and 68.82 ± 77.72 (p = NS) at 9 months. Sexual function: IIEF baseline 19.38 ± 6.25, 14.06 ± 8.65 at 1 month (p = .011), and 15.4 ± 8.41 at 9 months, (p = NS). Video review of patients with disorders showed potential damage at the site of ligation of IMA (high hypogastric plexus) in 1 case, lateral and posterior mesorectum dissection (hypogastric nerves) in 2 cases, anterior dissection of the Denonvilliers fascia from seminal vesicles in 2 cases. GUD at 1 month from LTME for rectal cancer are significant but improve at 9 months. Surgical video review of patients with GUD provides an important tool for detection of lesion sites.

Surgical anatomy of the sternoclavicular joint: a qualitative and quantitative anatomical study.

The quantitative anatomical relationships of the main ligamentous, tendinous, and osseous structures of the sternoclavicular joint have not been widely investigated. The purpose of this study was to provide a quantitative description of the sternoclavicular joint in relation to relevant surgical landmarks. We dissected eleven nonpaired, fresh-frozen cadaveric sternoclavicular joints from four men and seven women (mean age at death, fifty-three years; range, thirty-three to sixty-four years) and measured the ligaments, musculature, and osseous landmarks with use of a three-dimensional coordinate-measuring device. The clavicular pectoralis ridge, located at the 9:30 clock-face position on a right clavicle, served as a reliable osseous landmark for reference to the soft-tissue attachments around the sternoclavicular joint. The costoclavicular ligament was the largest ligament of the sternoclavicular joint, with 80% greater footprint area than that of the posterior sternoclavicular ligament. Articular cartilage covered 67% of the medial end of the clavicle and was located anteroinferiorly. The sternohyoid muscle inserted directly over the posterior sternoclavicular joint and the medial end of the clavicle, whereas the sternothyroid muscle inserted 9.5 mm inferior to the posterior-superior articular margin of the manubrium and coursed 19.8 mm laterally along the first rib. An avascular plane that can serve as a "safe zone" for posterior dissection was observed in each specimen, posterior to the sternoclavicular joint and anterior to the sternohyoid and sternothyroid muscles. The clavicular pectoralis ridge can be used as an intraoperative guide for clavicle orientation and tunnel placement in sternoclavicular ligament reconstruction. Sternoclavicular joint resection arthroplasty should avoid injuring the costoclavicular ligament, which is the largest sternoclavicular joint ligament. Resection of only the anteroinferior aspect of the medial end of the clavicle may provide adequate decompression while preserving the stability of the clavicle. The location of the sternohyoid and sternothyroid musculotendinous insertions appear to provide a "safe zone" for posterior clavicle and manubrial dissection.

Gluteal and Posterior Thigh Pain in the Postoperative Period and the Need for Intervention After Sacrospinous Ligament Colpopexy

One transvaginal option for surgical repair of vaginal apex prolapse is sacrospinous ligament (SSL) colpopexy. Several studies evaluating outcomes of SSL suspension have shown favorable results: the subjective success rate ranges from 84% to 99% and the objective success rate ranges from 67% to 93%. To facilitate the SSL colpopexy technique, the Capio suture-capturing device was developed in 1997. Safe suture placement into the SSL with easy suture retrieval has been achieved with this device. A postoperative complication of SSL colpopexy reported in a number of studies is gluteal and posterior thigh pain, which occurs in 6% to 14% of patients. Few studies have compared the Capio device with other suturing techniques used to perform the SSL colpopexy procedure, and none have investigated the incidence of gluteal and posterior thigh pain with this device. This retrospective cohort study determined the rate of gluteal and posterior thigh pain both in the immediate postoperative period and at the 6-week postoperative visit after use of the Capio device to perform SSL colpopexy in patients with vaginal apex prolapse. The risk for needing intervention for this type of pain was also investigated. The study was conducted at a single urogynecology center between 2007 and 2012. Demographic, intraoperative, and immediate as well as 6-week postoperative data were obtained from the electronic inpatient and outpatient medical records. A total of 242 women underwent SSL colpopexy with the Capio device for vaginal apex prolapse. The mean patient age and body mass index were 66 (10) years and 28.7 (5.4) kg/m2, respectively. Of the 242 patients, 134 (55.4%) experienced gluteal or posterior thigh pain immediately after surgery and 36 (15.3%) had persistent pain at 6 weeks. Five patients (2.1%) required intervention to manage pain (95% confidence interval, 0.8%-4.7%); interventions used were physical therapy (3), trigger point injection (1), or both (1), and no patient required reoperation. Pain at 6 weeks was associated with concomitant midurethral sling placement (P = 0.008) and the number of sutures placed: 4 sutures placed in the SSL was more likely to be associated with intervention than 2 or 3 sutures placed (60% vs 15.6%, P = 0.03). Neither concomitant hysterectomy nor anterior versus posterior dissection approach was associated with gluteal or posterior thigh pain. These data show a high rate of postoperative gluteal and posterior thigh pain immediately after SSL colpopexy for vaginal apex prolapse. The rate of pain at 6 weeks, however, is much lower, and the need for intervention was even lower.

Anterior and Posterior Bladder Neck Dissection with Tension Stitch

Abstract Introduction: In this video, we demonstrate both the anterior and the posterior bladder neck dissection with tension stitch. Placing a suture in the posterior bladder neck is a common approach in patients with median lobes, whereby the median lobe is retracted with a figure-of-eight suture. Materials and Methods: The 30-degree down lens is utilized for the most optimal view of this dissection. Results: Multiple visual cues are utilized to determine the location of the bladder neck, including the limits of the anterior prostatic fat pad, excursions of the Foley balloon, and tissue response to pinching maneuvers. The initial dissection focuses primarily in the midline, aiming to get down to vertical fibers, which appear just before the catheter is exposed. If the lateral contours of the prostate are readily apparent, this tissue may be taken down as well, bearing in mind that bleeding is often encountered laterally as shown. Once the catheter is exposed, some lateral progression will help define th...

Perineal robot-assisted laparoscopic radical prostatectomy: feasibility study in the cadaver model.

To evaluate the feasibility of perineal robot-assisted laparoscopic radical prostatectomy (P-RALP) in the cadaver model. The prostate was assessed by ultrasonography and cystoscopy in the lithotomy position. After incision and subcutaneous dissection, a single-port device was placed and the robot was docked. The rectourethralis muscle was divided and the levator ani fibers were split. The Denonvilliers fascia was incised and the posterior prostate and seminal vesicles were dissected. The apex was dissected and the urethra was transected. The anterior and lateral planes were dissected and the prostate pedicles were clipped. The prostate was freed from the bladder neck and the vesicourethral anastomosis was performed. The robot was undocked and the wound was sutured in layers. Cystoscopy confirmed integrity of the anastomosis. The specimen was sent for histopathology examination. Nerve-sparing P-RALP was successfully completed in three cadavers. Median time for setting was 23 minutes. Time for posterior dissection was 15 minutes. Dissection of the apex and section of the urethra took 9 minutes. Time for anterolateral dissection was 14 minutes. Time for bladder neck dissection was 7 minutes. Vesicourethral anastomosis took 8 minutes. Total operative time was 89 minutes. The prostate capsule was grossly intact and histopathology examination was negative for prostatic tissue in all distal urethral sections and in two of three bladder neck sections. P-RALP is feasible in the cadaver. Future studies should evaluate the feasibility of lymph node dissection through the same incision, clinical feasibility, and prospective comparisons with standard techniques.

Minipterional Craniotomy: An Alternative Approach for Sphenoid Wing Meningiomas

Objective: Minipterional craniotomy is a modification of the standard pterional (frontotemporal) craniotomy. It provides the same microsurgical exposure as the standard frontotemporal approach. Material and Methods: We analyzed the relation between the sphenozygomatic suture and the marginal tubercle of the frontal process of the zygoma 60 dried skulls. Minipterional craniotomy was performed in 10 cadaveric specimens. The approach was utilized to 12 sphenoid wing meningiomas. Results: The marginal tubercle was hiding the sphenozygomatic suture when it is > 8 mm, it required drilling to enhance the exposure. Anterior to posterior subperiosteal dissection and retraction of the temporalis muscle, and avoiding cuts along the origin of the muscle allows excellent cosmetic outcome. All 16 meningiomas were successfully resected without morbidity or mortality through a 3.5 to 4 cm bone flap. Conclusions: Minipterional approach is an excellent option to approach sphenoid wing meningiomas. The minimally invasive access allows minimal soft tissue trauma, smaller bony opening, less pain, and excellent cosmetic outcome.