Posterior Flap Research Articles

Free posterior interosseous artery perforator flap in the treatment of finger with skin and soft tissue defect

To explore clinical effects of repairing skin and soft tissue defect of finger with free posterior interosseous artery perforator flap. Totally 8 patients with finger skin and soft tissue defect repaired with free posterior interosseous artery perforator flap were treated from May 2021 to November 2022, including 7 males and 1 female aged from 24 to 54 years old, and soft tissue defect area ranged from 3.0 cm×1.5 cm to 5.0 cm×3.0 cm. The time from injury to flap repair ranged from 3 to 83 h. The free posterior interosseous artery perforator flap was applied to repair finger defect, the area of the flap ranged from 3.5 cm×2.0 cm to 5.2 cm×3.5 cm, the donor area of flap was sutured directly. The survival, appearance, texture and donor complications of the flap were observed after operation, and Dargan functional standard was used to evaluate clinical effect of finger function. All flap of 8 patients were survived, and followed up from 3 to 12 months. There was no obvious swelling, soft texture, obvious pigmentation, linear intaglio in donor area only, and without obvious complications were found. Among them, 3 patients'skin flaps were repaired for the defect of palm of the fingers, and sensory recovery was good, two-point discrimination ranged from 5 to 9 mm. According to Dargan functional evaluation, 3 patients excellent, and 5 good. Free posterior interosseous artery perforation branch flap could be used to repair the defect of finger. The thickness of flap is moderate, operation is convenient, appearance and texture of the operative flap are good, and the donor site is small without obvious complications, and obtain satisfactory clinical effect.

The distal fibular perforating axial flap for lateral malleolus coverage: an anatomical description and surgical technique.

Skin closure disorders in ankle surgery are a recurrent problem not only in traumatology but also in elective surgery. The aim of the study was to describe the anatomical basis of the fasciocutaneous vascularization of the lateral malleolus region to develop a posterior cover flap for the region. We dissected ten fresh frozen specimens after arterial injection of an Indian ink preparation and individualized the perforating arteries. Their positions and diameters were collated. Then, the surgical technique was clinically applied for two different cases by transferring the fasciocutaneous flap posterior to the lateral malleolus to cover a loss of skin substance. There were in average 5 fibular perforators over the last 100mm of the fibula. The average diameter of the first two perforating arteries was 0.6 ± 0.12mm and 0.9 ± 0.25mm, respectively, and the consistency of the latter makes it possible to produce a skin flap with anterior translation. This is an axial flap. Two patients were operated on using this technique. There was no necrosis of the posterior fibular flap and healing was achieved by the third post-operative week. This study showed the presence of fibular perforating arteries with a high reproducibility of their dissection. This anatomical description served as the basis for the description of a new distal fibular perforating flap.

Clinical application of double V-Y advancement mucosal flap to repair tongue defect.

The repair of small- and medium-sized defects in the oral tongue has always been a challenge, and the effect of free flap and distal pedicle flap is still far from satisfactory. Tongue flap is an ideal choice for repairing small- and medium-sized defects. However, the disadvantages such as poor local morphology restricts the development of this operation.This study aims to investigate the efficacy of double V-Y advancement mucosal flap in repair of small- and medium-sized defects of the tongue defect. The clinical data of 15 patients with tongue defect lesions who were hospitalized in the Department of Stomatology, Third Xiangya Hospital of Central South University from March 2019 to May 2022 were retrospectively analyzed. After the lesions were completely excised, the mucosa and part of the tongue defect were left. One V-Y advancement mucosal flap was designed anteriorly and posteriorly to the defect. The superficial mucosa was incised gradually all around, preserving the deep median muscle tip. The 2 flaps were freed toward the middle of the defect, and the anterior and posterior flaps were sutured together at the middle of the defect, with the donor area directly pulled together and sutured. The double V-Y advancement mucosal flap survived in 15 patients, and the wounds healed at stage I. The postoperative follow-up time was 12-22 months, and the patients had no recurrence, with symmetrical tongue shape, and no traction and deformation in the affected tongue organs. Meanwhile, the intraoral flap was thin and flat, and healed well with the surrounding mucosa, without obvious flap contracture or tongue bite. Double V-Y advancement mucosal flap has the advantages of flexible design, simple preparation, reliable blood supply, and good protection of the donor site, which may be one of the effective methods for repairing small- and medium-sized defects in the anterior tongue mucosa.

Novel operative technique for Scimitar syndrome: Posterior flap technique.

Various surgical techniques have been reported for Scimitar syndrome, because of the heterogenous anatomy of the disease. We developed a novel surgical method to repair Scimitar syndrome, in which, a new pulmonary venous route is constructed behind the inferior vena cava using autologous flaps of the inferior vena cava and the interatrial septum. An adult case of Scimitar syndrome was repaired by this method with good results.

Pharyngeal Flap Versus Sphincter Pharyngoplasty for the Treatment of Velopharyngeal Insufficiency in 22q11.2 Deletion Syndrome: Preliminary Findings From a Systematic Review.

The purpose of this study was to examine and compare surgical and speech outcomes of the posterior pharyngeal flap and sphincter pharyngoplasty following surgical management of velopharyngeal insufficiency in patients with 22q11.2 deletion syndrome (22q11.2DS). This systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses checklist and guidelines. Selected studies were chosen using a 3-step screening process. The 2 primary outcomes of interest were speech improvement and surgical complications. Preliminary findings based on included studies suggest a slightly higher rate of postoperative complications with the posterior pharyngeal flap in patients with 22q11.2DS but a lower percentage of patients needing additional surgery compared with the sphincter pharyngoplasty group. The most reported postoperative complication was obstructive sleep apnea. Results from this study provide some insight into speech and surgical outcomes following pharyngeal flap and sphincter pharyngoplasty in patients with 22q11.2DS. However, these results should be interpreted with caution due to inconsistencies in speech methodology and lack of detail regarding surgical technique in the current literature. There is a significant need for standardization of speech assessments and outcomes to help optimize surgical management of velopharyngeal insufficiency in individuals with 22q11.2DS.

Revision of the Western Indian Ocean Angel Sharks, Genus Squatina (Squatiniformes, Squatinidae), with Description of a New Species and Redescription of the African Angel Shark Squatina africana Regan, 1908.

Sampling efforts on the Saya de Malha Bank (part of the Mascarene Plateau, western Indian Ocean) unveiled three unusual small juvenile angel shark specimens, that were a much paler color than the only known western Indian Ocean species, Squatina africana Regan, 1908. However, it took many years before further specimens, including adults of both sexes, and tissue samples were collected. The present manuscript contains a redescription of S. africana based on the holotype and additional material, as well as the formal description of the new species of Squatina. All specimens of the new species, hereafter referred to as Squatina leae sp. nov., were collected in the western Indian Ocean off southwestern India and on the Mascarene Plateau at depths of 100-500 m. The new species differs from S. africana in a number of characteristics including its coloration when fresh, smaller size at birth, size at maturity, and adult size, genetic composition, and distribution. Taxonomic characteristics include differences in the morphology of the pectoral skeleton and posterior nasal flap, denticle arrangement and morphology, vertebral counts, trunk width, pectoral-pelvic space, and clasper size. A key to the species of Squatina in the Indian Ocean is provided.

A Tunneled Posterior Auricular Transposition Flap for Ear Concha Defect

Surgical treatment of ear defects requires the awareness of reconstructive concepts. Acceptable cosmetic appearance is not always achievable because of its complex anatomy, a limited availability of soft tissue around defects and a great number of aesthetic units. Retro-auricular zone is frequently applied as a flap donor area because of its rich vascularization. While repairing of the ear defects, three-dimensional structure and different plane of the ear on the mastoid surface should be taken into consideration very carefully. In this case we present a case of basal cell carcinoma on the concha of the ear. The resulting defect was repaired with a tunneled posterior auricular transposition flap which provided a good aesthetic result.

The Agonist-Antagonist Myoneural Interface in a Transtibial Amputation.

The agonist-antagonist myoneural interface (AMI) technique at the time of transtibial amputation involves the use of agonist-antagonist muscle pairs to restore natural contraction-stretch relationships and to improve proprioceptive feedback when utilizing a prosthetic limb1. Utilizing the standard incision for a long posterior myofasciocutaneous flap, the lateral and medial aspects of the limb are dissected, identifying and preserving the superficial peroneal and saphenous nerve, respectively. The tendons of the tibialis anterior and peroneus longus are transected distally to allow adequate length for the AMI constructs. After ligation of the anterior tibial vessels, the deep peroneal nerve is identified and tagged to create a regenerative peripheral nerve interface (RPNI). The tibia and fibula are cut approximately 15 cm from the medial joint line, facilitating dissection of the deep posterior compartment and ligation of the peroneal and posterior tibial vessels. The tendons of the lateral gastrocnemius and tibialis posterior are transected distally, and the amputation is completed. The extensor retinaculum is harvested from the residual limb along with multiple 2 × 3-cm free muscle grafts, which will be used for the RPNI constructs. The retinaculum is secured to the tibia with suture anchors, and AMI pairs of the lateral gastrocnemius and tibialis anterior as well as the tibialis posterior and peroneus longus are constructed. Separate RPNIs of the major lower-extremity nerves are performed, and the wound is closed in a standard layered fashion. An isometric myodesis of the gastrocnemius without coaptation of agonist-antagonist muscle pairs can be performed at the time of transtibial amputation. The AMI technique restores natural agonist-antagonist relationships at the time of transtibial amputation to increase proprioceptive feedback and improve prosthetic control. These outcomes contrast with those of a traditional isometric myodesis, which prevents proprioceptive communication from the residual limb musculature to the central nervous system. Additionally, the AMI technique allows for concentric and eccentric muscular contractions, which may contribute to the maintenance of limb volume and aid with prosthetic fitting, as opposed to the typical limb atrophy observed following standard transtibial amputation1,2. With the development and availability of more advanced prostheses, the AMI technique offers more precise control and increases the functionality of these innovative devices. Early clinical outcomes of the AMI technique at the time of transtibial amputation have been promising. In a case series of the first 3 patients who underwent the procedure, complications were minor and consisted of 2 episodes of cellulitis and 1 case of delayed wound healing1. Muscle activation measured through electromyography demonstrated an improved ability to limit unintended muscular co-contraction with attempted movement of the phantom limb, as compared with patients who underwent a standard transtibial amputation1. Additionally, residual limb volume was maintained postoperatively without the need for substantial prosthetic modifications. The tendons of the tibialis anterior, peroneus longus, tibialis posterior, and lateral gastrocnemius should be transected as distal as possible to allow adequate length for creation of the AMI constructs.Approximately 2 × 3-cm free muscle grafts are harvested from the amputated extremity for RPNI3.Smooth tendon-gliding through the synovial tunnels should be confirmed before closure. If necessary, muscle debulking can improve gliding and decrease the size of the residual limb.Harvesting the extensor retinaculum for synovial tunnels has been our preferred method, although we acknowledge that other grafts options such as the tarsal tunnel are available1. RPNI = regenerative peripheral nerve interfaceAMI = agonist-antagonist myoneural interfaceEMG = electromyographic.

Using a Novel Method to Quantify and Confirm the Variable Vertical Vector of the Deep Plane Facelift.

Background: In deep plane rhytidectomy, it is accepted that a more vertical vector will lead to a more natural rejuvenated look than a horizontal vector of pull. Objective: Among patients undergoing deep plane rhytidectomy, can skin angle measurements designed by the authors be used as a proxy for vector of tension to confirm a vertical vector? Methods: Case series measuring the rhytidectomy vector of pull for a series of patients performed by a single surgeon. Results were compared between the vectors of the pre- and postauricular flaps as well as comparing the vector of pull in male versus female patients, patients undergoing facelift alone versus in conjunction with other rejuvenation procedures, and between primary versus revision rhytidectomy patients. Results: Patient characteristics: Average age 64.4 (range 47-79), predominantly female (26/28, 92.9%), primary rhytidectomy (24/28, 85.7%), with concomitant brow lift (12/28, 42.9%). Results reveal a more vertical than horizontal vector of pull on both the pre- and postauricular superficial musculoaponeurotic system flaps with the vector of the anterior flap being more vertical than that of the posterior flap. Conclusion: Utilizing a novel proxy measurement, the vector of pull of the deep plane facelift was more vertical than horizontal.

Maximizing Solid Organ and Face Transplant Procurement Team Coordination: The Posterior Tibial Artery Flap as an Ideal Sentinel Flap

Face transplantation became a reality with the first case performed in 2005. Facial tissue allograft procurement is technically complex and time-intensive. Brain-dead deceased donors are frequently, if not always, multiorgan donors. Every effort should be made during face allograft recovery to minimize any risk to the recovery of lifesaving solid organs. Some programs require the procurement of a myofascial vascularized skin graft to function as a sentinel flap allowing frequent monitoring for rejection without negatively impacting the esthetics of the face graft. Up till now, the flap used has been the radial forearm flap. Procuring the radial forearm flap places the procuring team in close proximity to the head and torso, where the face recovery and the solid organ recovery teams would require unhindered access. Here, we present the posterior tibial artery flap as an alternative flap that would provide benefits to the coordination of the multiple teams working to procure organs from a deceased donor.

Soft Palate Dysplasia: Properties and Surgical Techniques.

The authors aimed to report a hitherto undescribed class of patients with the obvious phenotype of a novel soft palate dysplasia (SPD) combining unilateral soft palate hypoplasia with a fully developed uvula. The authors also aimed to investigate and evaluate the corresponding surgical approaches. Twelve patients were clinically diagnosed with SPD. Clinical examination, including radiographic tests, was performed to characterize the congenital deformity. The effectiveness of velopharyngeal closure and speech were tested preoperatively and postoperatively. SPD was featured with velopharyngeal insufficiency, food regurgitation, and speech disorders. It was commonly manifested as structural deformities of the soft palate, tongue palatine arch, pharyngeal palatine arch, and pterygomandibular fold, but with complete uvula shape. According to radiographic analysis, in five patients, the lateral pterygoid processes were poorly developed, and other malformations were present. Velopharyngoplasty based on the unilateral posterior pharyngeal flap can well restore the velopharyngeal closure and speech intelligibility without respiration obstruction. SPD is characterized as congenital velopharyngeal insufficiency manifested as a primary soft palate defect. It is highly associated with other physical deformities but independent of conventionally known syndromes. The cause may be an abnormal development of the pterygoid process. Unilateral velopharyngoplasty based on the posterior pharyngeal flap is a great technique to repair SPD. Therapeutic, IV.

Comparing the success rate of external dacryocystorhinostomy with anterior flap versus flap excision in managing chronic dacryocystitis.

Nasolacrimal duct obstruction (NLDO) is characterized by epiphora and recurrent episodes of acute dacryocystitis. Despite the temporary effect of antibiotics in the acute phase, it is primarily managed by dacryocystorhinostomy (DCR). There is a new modification of external DCR that is performed without either anterior or posterior flaps. This study aimed to compare the outcomes of flapless and single-flap external DCR in adult patients with chronic symptomatic dacryocystitis secondary to NLDO. In this retrospective, non-randomized, interventional, comparative study of patients with chronic dacryocystitis secondary to primary acquired NLDO, we compared the surgical outcomes and complication rates of flapless external DCR to those of external DCR with only anterior flap suturing. We excluded patients who declined participation and those with soft stops, nasal problems, lid margin abnormalities, lid malposition or laxity, previous lacrimal surgery, lacrimal fistula, trauma involving the lacrimal drainage system, lack of adequate follow-up, or severe septal deviation or turbinate hypertrophy. Anatomical and functional success rates were determined at the last follow-up visit and were compared. Postoperative complications were recorded and compared between groups. We included 53 patients with a male-to-female ratio of 16 (30.2%) to 37 (69.8%); 25 eyes underwent flapless DCR (group 1) and 28 eyes underwent anterior flap suturing DCR (group 2). The two groups had comparable demographic characteristics (all P > 0.05). Furthermore, anatomical (92.0% in group 1 and 92.9% in group 2) and functional (84.0% in group 1 and 92.9% in group 2) success rates at final follow-up were comparable between groups (both P > 0.05). At the one-month postoperative examination, premature tube extrusion was more often reported in group 1 (12.0%) compared to group 2 (7.1%). At the two-month follow-up examination, tube extrusion was noted in 4.0% in group 1 and 0.0% in group 2, yet the difference failed to attain statistical significance (P > 0.05). We found that neither surgical method was superior in terms of anatomical or functional success rate at a maximum of one year after external DCR. Flapless DCR is a simple, effective, and reproducible alternative to the single anterior flap suturing technique for managing NLDO in adults with chronic dacryocystitis. However, further randomized clinical trials with larger sample sizes and longer follow-up periods are recommended before generalization can be justified.

Propeller posterior tibial artery perforator flap for reconstruction of the medial malleolar defect: A case report

Abstract Traumatic injury to the distal third of the lower leg remains challenging and often requires free tissue transfer. Reconstructive options for lower leg soft-tissue defects require comprehensive evaluation. A 20-year-old man presented with a medial malleolar soft-tissue defect with exposure of the great saphenous vein, distal tibia, and ankle joint after a traffic accident. Negative pressure wound therapy provided only partial coverage of the exposed tissue. The defect was reconstructed using a local fasciocutaneous propeller flap based on a septocutaneous perforator from the posterior tibial artery. At 1-year follow-up, the patient resumed normal daily activities without functional deficits. We review the options of reconstructing the distal third of the lower leg and surgical pearls of propeller flaps. Propeller flaps provide adequate tissue-like and pliable soft tissue coverage with a short operation time. It can be a useful technique for the reconstruction of distal third lower-leg defects.

P23 A STRANGE CASE OF CERVICALGIA

Abstract 65–year–old patient with a history of Type 2 Diabetes Mellitus on oral hypoglycaemic therapy, hypercholesterolemia, previous diagnosis of non–secreting K–chain micronodular myeloma undergone heterologous marrow transplantation. From January 2022, he presented persistent mild–moderate neck pain and feverish episodes, therefore he started empiric antibiotic therapy at home. Since June 2022, he complained a worsening of the neck pain partially controlled by non–steroidal anti–inflammatories. Magnetic resonance imaging was therefore performed which highlighted findings consistent with spondylitis of probable infectious nature and subsequent start of empiric antibiotic. A bone marrow biopsy was also performed which showed no recurrence of myelopathy. In July 2022 new feverish episode with shaking chills lasting about 3 days. In this circumstance he underwent a blood culture which resulted positive for the presence of Str. Bovis. In addition, a transthoracic echocardiogram was performed and showed evident floating serpiginous vegetation on the anterior mitral leaflet measuring approximately 1.2 cm x 2.5 cm with a mild mitral regurgitation. Targeted antibiotic therapy was set up and abdominal ultrasound and brain MRI were performed which excluded splenic and brain embolization. A close echocardiographic follow–up showed no reduction of the vegetation. So the patient underwent cardiac surgery in thoracotomy to remove the vegetation adhered to the anterior mitral flap in A2 on the atrial side (3 cm x 1.5 cm x 0.5 cm), and also removal of millimetric lesions on the posterior flap and abrasion of the implantation areas. The post–surgery clinical course passed without any complications, the patient remained stably afebrile with a progressive reduction of the inflammation indexes. Approximately 10 days post–surgery, the patient was then discharged with indications for echocardiographic follow–up.

P271 CASEOUS CALCIFICATION OF THE MITRAL ANNULUS: ROLE OF 3D ECHOCARDIOGRAPHY

Abstract The caseous calcification of the mitral annulus (CCMA) is a rare degenerative condition of the mitral valve (0.067% prevalence in the general population) that generally affects older women with hypertension, chronic kidney disease and dyslipidemia. Usually CCMA is asymptomatic and it is associated with mild to moderate mitral regurgitation and it can cause severe mitral valve dysfunction that requires surgical treatment. CASE 1: A 84–year–old woman, with arterial hypertension, was evaluated in our clinic to perform a transthoracic echocardiogram (TTE) for a previous finding of heart murmur. TTE reveled at the level of the posterior mitral annulus a hyperechoic roundish formation with a central eco–shiny area with a maximum diameter of 20x20 mm. A tridimensional trans–esophageal echocardiography (3D TEE) allowed a better characterization of the mass showing well–defined contours, adhered to the posterior mitral annulus, systolic dislocation of the anterior mitral leaflet, with slight mitral regurgitation. Considering the morphological characteristics of the mass we concluded for a presumptive diagnosis of CMAC. We recommended regular follow–up to the patient. After 6 and 12 months the mass did not change in size and echostructure. CASE 2: An 88–year–old woman with chronic kidney disease, high blood pressure and chronic ischemic heart disease was admitted to our ward for acute heart failure. TTE showed a large an echodense mass (43 × 19 mm) involving the posterior mitral annulus, with a central echo–lucent area. A 3D TEE was performed with better mass characterization: involvement of the entire posterior mitral ring, reduced movement of the posterior mitral flap, anterior mitral flap with normal morphology and normal mobility. In consideration of the echocardiographic characteristics we concluded for the presence of CMAC. We discharged the patient with indication for a regular clinical and echocardiographic follow–up. Conclusions The 3D TTE provides adequate morphostructural information that allows in most cases to characterize the CCAM. When the transthoracic approach is difficult due to poor acoustic windows, 3D TEE can be used. Only in rare cases it is necessary to use second–level diagnostic tests such as CT and Cardiac Magnetic Resonance Imaging.

Short-Term Complications of Relative Femoral Neck Lengthening Combined with Extra-Articular Osteotomies of the Proximal Femur.

Relative femoral neck lengthening (RNL) is a newer technique to correct coxa breva and coxa vara to relieve a femoro-acetabular impingement and improve hip abductor function without changing the position of the head on the shaft. Proximal femoral osteotomy (PFO) changes the position of the femoral head relative to the shaft. We studied the short-term complications of procedures that combined RNL with PFO. All hips that underwent RNL and PFO using a surgical dislocation and extended retinacular flap development were included. Hips that were treated only with intra-articular femoral osteotomies (IAFO) were excluded. Hips that underwent RNL and PFO, with IAFO and/or acetabular procedures were included. Intra-operative evaluation of the femoral head blood flow was performed with the drill hole technique. Clinical evaluation and hip radiographs were obtained at 1week, 6weeks, 3months, 6months, 12months and 24months. Seventy two patients (31 males, 41 females, 6-52years of age) underwent 79 combined RNL and PFO. 22 hips underwent additional procedures like head reduction osteotomy, femoral neck osteotomy, and acetabular osteotomies. There were 6 major and 5 minor complications noted. Two hips developed non-unions, both with basicervical varus-producing osteotomies. Four hips developed femoral head ischemia. Two of these hips avoided collapse with early intervention. One hip had persistent abductor weakness requiring hardware removal and three hips, all in boys developed symptomatic widening of the hip on the operated side from varus-producing osteotomy. One hip had asymptomatic trochanteric non-union. RNL is routinely performed by releasing the short external rotator muscle tendon insertion from the proximal femur to raise the posterior retinacular flap. Though this technique protects the blood supply from direct injury, it seems to stretch the vessels with major corrections in the proximal femur. We recommend evaluating the blood flow intraoperatively and postoperatively and taking necessary steps early to decrease the stretch on the flap. It may be safer to avoid raising the flap for major extra-articular proximal femur corrections. The results of this study suggest ways to improve the safety of procedures that combine RNL and PFO.

Surgical treatment of postauricular hidradenitis suppurativa with delayed diagnosis: a case report and literature review.

Hidradenitis suppurativa (HS) is a chronic inflammatory condition that is difficult to diagnose, with a period of 10.0± 9.6 years from symptom onset to diagnosis. A 32-year-old Asian man presented with bilateral postauricular abscesses that first appeared 5 years previously. Despite several incisions and drainage, the symptoms only temporarily improved and continued to recur. On physical examination, chronic scars and sinus tracts were observed around the lesion. Postauricular HS was diagnosed, and surgical treatment was performed. We performed a wide excision and reconstructed the defect using a posterior auricular artery perforator-based keystone flap. Histological examination confirmed the diagnosis of HS. The reconstruction was successful, and there was no recurrence for 2 years after surgery. HS is difficult to diagnose without specific attention. Although the postauricular region is not a typical site of HS, it can occur in this area. Therefore, if a patient presents with recurrent abscesses in the postauricular region, HS should be considered. Additionally, if HS is diagnosed in the postauricular region, wide excision with reconstruction using a posterior auricular artery perforator-based keystone flap can lead to a favorable outcome.

Reliability and Versatility of Posterior Interosseous Artery Flap in Reconstructing Hand Soft Tissue Defects

Reliability and Versatility of Posterior Interosseous Artery Flap in Reconstructing Hand Soft Tissue Defects

MP07-06 TWELVE YEAR EXPERIENCE WITH SALVAGE ROBOTIC SACROCOLPOPEXY. SURGICAL TECHNIQUE AND REASONS FOR FAILURE IN THE INITIAL SURGERY

You have accessJournal of UrologyCME1 Apr 2023MP07-06 TWELVE YEAR EXPERIENCE WITH SALVAGE ROBOTIC SACROCOLPOPEXY. SURGICAL TECHNIQUE AND REASONS FOR FAILURE IN THE INITIAL SURGERY Cassandra Schuster, Spencer Kortum, Benjamin Behers, Genesis Dolgetta, Karim Ghazli, Victoria Bird, and Robert Carey Cassandra SchusterCassandra Schuster More articles by this author , Spencer KortumSpencer Kortum More articles by this author , Benjamin BehersBenjamin Behers More articles by this author , Genesis DolgettaGenesis Dolgetta More articles by this author , Karim GhazliKarim Ghazli More articles by this author , Victoria BirdVictoria Bird More articles by this author , and Robert CareyRobert Carey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic sacrocolpopexy (RASCP) is a transabdominal approach for repair of pelvic organ prolapse (POP) that reliably provides durable repair of high grade prolapse. Although reoperation for recurrent prolapse after RASCP should be a rare event, the techniques and problems associated with robotic salvage in these cases is under reported. METHODS: Data is collected from an IRB-approved prospectively maintained database of robotic POP repair in a tertiary care hospital. The surgery is performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port by a single surgeon. Commercially available 4×24 cm Y-shaped wide pore polypropylene mesh is modified to accommodate the anterior and posterior dissections of the vaginal walls and these are attached with running barbed suture with 16-20 sites of fixation. The long Y-arm of the mesh is trimmed to size for attachment to the anterior longitudinal ligament with GoreTex sutures. Posterior peritoneal flaps are created and the entirety of the mesh and repair is completely covered by peritoneum. No mesh or suture is left exposed. Mid-urethral slings were placed at the time of salvage RASCP (sRASCP) to prevent de novo stress incontinence. All repairs restored maximal vaginal length and desired vaginal axis. All patients for RASCP had stage 4 prolapse. There were no conversions from robotic to open. RESULTS: Between 2010 and 2022, a total of 450 patients underwent RASCP at the same institution. 8 (1.8%) were done in the salvage setting with a previous attempt at open or RASCP performed and pre-existing mesh inside the abdomen. On reoperation for these RASCP patients for the purpose of salvage, 8/8 (100%) were found to have no connectivity of the mesh to the anterior longitudinal ligament (ALL). 4/8 (50%) had no connectivity to the either the anterior or posterior vaginal vault. Mean age at salvage operation was 69.5 years and mean BMI 28.5. Cases were completed with robotic console time between 105 and 123 minutes. CONCLUSIONS: sRASCP is a safe and durable surgery for repair of prolapse in the setting of a failed first attempt of RASCP with pre-existing mesh. Every case achieved excellent repair of prolapse. The most common finding is these cases was non-attachment of the mesh to the ALL. All patients required dissection of the ALL for appropriate mesh attachment. Pre-existing mesh can be used to help in repair as long as there is appropriate attachment to the vaginal vault. Pre-existing mesh should be excised if there is no useful vaginal or ALL attachment. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e86 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cassandra Schuster More articles by this author Spencer Kortum More articles by this author Benjamin Behers More articles by this author Genesis Dolgetta More articles by this author Karim Ghazli More articles by this author Victoria Bird More articles by this author Robert Carey More articles by this author Expand All Advertisement PDF downloadLoading ...

MP07-05 RISK FACTORS ASSOCIATED WITH POST-OPERATIVE SMALL BOWEL OBSTRUCTION FOLLOWING ROBOTIC SACROCOLPOPEXY WITH 12-YEAR EXPERIENCE

You have accessJournal of UrologyCME1 Apr 2023MP07-05 RISK FACTORS ASSOCIATED WITH POST-OPERATIVE SMALL BOWEL OBSTRUCTION FOLLOWING ROBOTIC SACROCOLPOPEXY WITH 12-YEAR EXPERIENCE Cassandra Schuster, Benjamin Behers, Spencer Kortum, Genesis Dolgetta, Karim Ghazli, Victoria Bird, and Robert Carey Cassandra SchusterCassandra Schuster More articles by this author , Benjamin BehersBenjamin Behers More articles by this author , Spencer KortumSpencer Kortum More articles by this author , Genesis DolgettaGenesis Dolgetta More articles by this author , Karim GhazliKarim Ghazli More articles by this author , Victoria BirdVictoria Bird More articles by this author , and Robert CareyRobert Carey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic sacrocolpopexy (RASCP) is a transabdominal approach for repair of pelvic organ prolapse (POP) that avoids placement of transvaginal mesh and provides durable repair of high grade prolapse. Given that the procedure has a trans-peritoneal component, there is a risk of reoperation due to small bowel obstruction (SBO). METHODS: Data was collected from an IRB-approved prospectively maintained database of RASCP in a tertiary care hospital. The surgery is performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port by a single surgeon. Commercially available 4×24 cm Y-shaped wide pore polypropylene mesh is modified to accommodate the anterior and posterior dissections of the vaginal walls and are attached with running barbed suture with 16-20 sites of fixation. The long Y-arm of the mesh is trimmed to size for attachment to the anterior longitudinal ligament with GoreTex sutures. Posterior peritoneal flaps are created and the entirety of the mesh and repair is completely covered by peritoneum. No mesh or suture is left exposed. Mid-urethral slings were placed at the time of sacrocolpopexy to prevent de novo stress incontinence. All patients for RASCP had stage 4 prolapse. There were no conversions from robotic to open. RESULTS: Between 2010 and 2022, 450 patients underwent RASCP at the same institution. 80 (17.8%) involved extensive lysis of adhesions (ELOS) and 370 did not code for ELOS. At mean 78-month (12–140 month) follow-up, there were 8 (1.8%) reoperations for SBO. 6/80 (7.5%) patients with ELOS had reoperations for SBO had ELOS. Age, BMI, procedure time, suture type, and brand of mesh were not associated with SBO. Only ELOS was found to be associated with SBO on multivariate analysis. Mean age was 66.1 years and mean BMI 28.2. Robotic console time between 59 and 123 min. All 8 reoperations for SBO had previous abdominal procedures, and 6 were coded as ELOS. There were no reoperations for SBO in patients with no previous abdominal surgery. CONCLUSIONS: RASCP is a safe and durable surgery for repair of POP. Risk of reoperation for SBO is associated with concomitant ELOS. In ELOS patients the risk of SBO is 7.5% and in patients without ELOS the risk is 0.5%. Although many patients presenting for RASCP have had previous abdominal operations, not all such patients require ELOS. For patients with histories of numerous prior bowel or abdominal surgeries who are at increased risk for ELOS at time of RASCP, careful patient selection is recommended and appropriate preoperative counseling suggested. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e86 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cassandra Schuster More articles by this author Benjamin Behers More articles by this author Spencer Kortum More articles by this author Genesis Dolgetta More articles by this author Karim Ghazli More articles by this author Victoria Bird More articles by this author Robert Carey More articles by this author Expand All Advertisement PDF downloadLoading ...