Preferred Surgical Modality Research Articles

The 3D-Printed Custom Elbow Prosthesis for Salvage Treatment of Complex Intra-Articular Distal Humerus Fracture Malunion

Intra-articular fractures of the distal humerus are complex injuries that often require surgery with the goal of restoring elbow range-of-motion and function. Open reduction and internal fixation has been the preferred surgical modality; however, restoration of the medial and/or lateral columns can be complicated in fractures involving a major loss of the articular surface and bony structure. Over the past decade, 3-dimensional (3D) printing has made significant advances in the field of orthopedic surgery, specifically in guiding surgeon preoperative planning. Recently, the incorporation of 3D-printing has proven to provide a safe and reliable construct for the restoration of anatomy in complex trauma cases. We present a 47-year-old woman who sustained a complex, intra-articular distal humerus fracture with associated shearing of the capitellum that went onto malunion. Patient was treated with a patient-specific 3D-printed custom elbow prosthesis with excellent outcomes. Our goal was to shed light on the use of 3D-printing technology as a viable salvage option in treating complex, intra-articular distal humeral fractures associated with lateral condylar damage that subsequently went onto malunion.

Impact of preferred surgical modality on surgeon wellness: a survey of workload, physical pain/discomfort, and neuromusculoskeletal disorders

BackgroundWe compared surgeons’ workload, physical discomfort, and neuromusculoskeletal disorders (NMSDs) across four surgical modalities: endoscopic, laparoscopic, open, and robot-assisted (da Vinci Surgical Systems).MethodsAn electronic survey was sent to the surgeons across an academic hospital system. The survey consisted of 47 questions including: (I) Demographics and anthropometrics; (II) The percentage of the procedural time that the surgeon spent on performing each surgical modality; (III) Physical and mental demand and physical discomfort; (IV) Neuromusculoskeletal symptoms including body part pain and NMSDs.ResultsSeventy-nine out of 245 surgeons completed the survey (32.2%) and 65 surgeons (82.2%) had a dominant surgical modality: 10 endoscopic, 15 laparoscopic, 26 open, and 14 robotic surgeons. Physical demand was the highest for open surgery and the lowest for endoscopic and robotic surgeries, (all p < 0.05). Open and robotic surgeries required the highest levels of mental workload followed by laparoscopic and endoscopic surgeries, respectively (all p < 0.05 except for the difference between robotic and laparoscopic that was not significant). Body part discomfort or pain (immediately after surgery) were lower in the shoulder for robotic surgeons compared to laparoscopic and open surgeons and in left fingers for robotic surgeons compared to endoscopic surgeons (all p < 0.05). The prevalence of NMSD was significantly lower in robotic surgeons (7%) compared to the other surgical modalities (between 60 and 67%) (all p < 0.05).ConclusionsThe distribution of NMSDs, workload, and physical discomfort varied significantly based on preferred surgical approach. Although robotic surgeons had fewer overall complaints, improvement in ergonomics of surgery are still warranted.Graphical abstract

Clinicoradiologic Risk Stratification and Outcome Assessment in Symptomatic Intracranial Arachnoid Cyst Managed Over Fifteen Years

Arachnoid cysts (ACs) are developmental anomalies formed by splitting the arachnoid membrane's layers. ACs contribute around 2% of all intracranial space-occupying lesions. ACs are more prevalent in children. Because of varied clinical presentation, there has been a constant need for clinicoradiologic risk stratification with a possible role in outcome prediction. The present study describes the management strategies and outcomes in symptomatic intracranial ACs. All biopsy-proven symptomatic patients who underwent surgical management over last 15 years were included in this study (January 2008-December 2022), while those with non-conclusive biopsies were excluded. Patients presenting with acute deterioration were managed in the emergency department with or without cerebrospinal fluid diversion and decompression of the AC. The microsurgical or endoscopic approach was the preferred surgical modality. Postoperative clinicoradiologic improvement was evaluated at 3 months follow-up visit. A total of 108 patients were analyzed in this retrospective observational study. The median age of the patients was 27.5 years (range, 1 to 76 years). Headache was the most typical clinical presentation. Supratentorial ACs (n= 59, 54.6%) were higher than the infratentorial ACs (n= 49, 45.4%). Forty-seven patients belonged to the pediatric age group (<18 years), and seizure was their presenting complaint. In this observational study, there was no statistical difference in operative duration between microsurgical technique versus endoscopic decompression (P= 0.23). ACs are uncommon brain lesions having a broad spectrum of symptoms. The location and clinical presentation of ACs decide the preferred surgical approach. Individuals in high-risk groups must be treated on priority to achieve long-term relief of symptoms.

Anatomical Description of Anterior Parametrium: AProbable Answer to Pelvic Recurrence Following Radical Hysterectomy.

A prospective analysis of a retrospective data of patients with cervix carcinoma treated by minimal invasive surgery at high-volume gynecology oncology center analyzing that minimal access surgery is an acceptable treatment modality in cervix carcinoma. The study included 423 patients who underwent laparoscopic/robotic radical hysterectomy after pre-operative evaluation after taking their consent and obtaining ethical approval from the IRB. Post-operatively, patients were followed up at regular intervals for clinical examination and ultrasonography for a median range of 36months. A PET scan was done only if there was any suspicious finding on clinical examination or ultrasonography. Patients with parametrial involvement, positive vaginal margins, and nodal involvement were treated with chemotherapy/radiotherapy. Four hundred twenty-three patients of cervix carcinoma were treated with minimal access surgery. Average duration of surgeries was 92min. Median range of duration of post-operative follow-up was 36months. None of the patients had positive resection margins indicating adequate parametrectomy with complete oncological clearance. On post-operative follow-up, only 2 patients had vaginal recurrence which is comparable to that observed in open surgery and no pelvic recurrence. With the understanding of the anatomical landmarks of the anterior parametrium and development of skills for adequate oncological clearance, minimal access surgery should be the preferred surgical modality in carcinoma of the cervix.

Endoscopic Stapedotomy: Overcoming Limitations and Improving Surgical Outcomes

Background: Stapedotomy is being practiced as a preferred surgical modality for the management of otosclerosis. The operating microscope has been utilized as the conventional tool for stapes surgery over the years. However, certain shortcomings too have been observed. Endoscope provides better and wider field of vision than an operating microscope. Aims and Objectives: The study is aimed to compare the technical challenges faced during microscopic versus endoscopic stapedotomy. Material and Methods: Forty patients with diagnosed otosclerosis were randomly assigned into 2 groups- patients in first group underwent microscopic stapedotomy, while the other group underwent endoscopic stapedotomy. The 2 groups were then observed in terms of extent of the postero- superior canal bone curettage/drilling required for clear visualization of operating area, need for chorda tympani manoeuvring, visualization of the incudo- stapedial complex, operative time, ease of piston insertion, patient head positioning, post-operative pain, vertigo, effect on hearing and taste impairment. Result: Endoscopic stapedotomy offered better access to the oval window requiring less bone removal and chorda tympani manoeuvring. The operating time, pain post operatively, and taste impairment were significantly less in the endoscopic group. No significant difference was observed with respect to hearing outcome and post operative vertigo. Endoscopic stapedotomy had disadvantage of handling the endoscope with one hand and placing the piston with other. Conclusion: Endoscopic stapedotomy has clear cut advantage over microscopic stapedotomy in terms of the technicality and accessibility to the operating area.

Laparoscopic Sacrocervicopexy Using Ethibond Suture Graft: A Very Economic Yet Effective Fertility Preserving Surgery for Pelvic Organ Prolapse.

The modern era has witnessed a transition to a phase of uterus-preserving surgeries and so holds true for pelvic organ prolapse (POP) surgeries as well. Laparoscopic sacrocervicopexy has become a preferred surgical modality for moderate to severe degrees of POP in most women of the childbearing age group. With the alarming incidences of mesh erosion, synthetic mesh has almost gone offthe market. We advocate a very simple and cost-effective technique of laparoscopic sacrocervicopexy using an Ethibond suture graft. It was a pilot prospective observational study over one year. Consecutive consenting women with symptomatic prolapsed uterus Stage-II of the central component of the quantitative POP classification (POP-Q) were recruited. Laparoscopic sacrocervicopexy was performed under general anesthesia using the standard protocols, and patients were prospectively followed for six months after surgery. The duration of surgery and hospital stay were noted. Patient satisfaction was rated using a five-point Likert scale. The vaginal length was measured immediately after and six months post-surgery. Sexual function was assessed using the validated female sexual function index (FSFI) scale six months after sacrocervicopexy. Out of 28 recruited women, the majority were multiparous, highly qualified, and belonged to the middle socio-economic class. Seven patients had co-morbidity in the form of hypertension (17.8%), diabetes (7.1%), and cardiovascular diseases (7.1%). The mean duration of surgery was 105.8±7.2 minutes in the study population. The mean duration of hospital stay was 2.2±0.6 days. No surgical site infection was noted in any of the cases. Most patients rated "very satisfied" experiences following surgery (67.9%). The mean vaginal length after surgery was 7.6±1.2 centimeters. After a follow-up period of six months, the mean vaginal length was 7.4±0.8 centimeters. The mean FSFI score was 30.8±2.4. Laparoscopic sacrocervicopexy with Ethibond suture graft is a cost-effective and safe surgical technique for POP in resource-limited settings. It also obviates the additional cost of synthetic mesh and the long-term risks of mesh erosion.

A Meta-analysis of Surgical Interventions for Base of Thumb Arthritis.

Background There is a myriad of available surgical options for thumb carpometacarpal joint (CMCJ) arthritis and no robust evidence exists to guide the decisions of treating surgeons. Our aim was to assess the comparative effectiveness of different surgical interventions available for the treatment of thumb CMCJ arthritis. Methods We performed a systematic review, pairwise, and network meta-analysis of all randomized studies comparing surgical interventions for thumb CMCJ arthritis. Our primary outcomes were pain, function, and key pinch strength at long-term follow-up (> 6 months). Risk of bias and certainty of evidence were assessed for each outcome measure of compared interventions separately. Clinical recommendations were based on evidence of strong or moderate certainty. Results A total of 17 randomized studies were included in the systematic review. Where possible, pairwise and network meta-analyses were performed. Based on evidence of moderate certainty, trapeziectomy with a concomitant ligament reconstruction and tendon interposition (LRTI) does not appear to be associated with any long-term clinical benefits compared with simple trapeziectomy (function: mean difference [MD] -3.72 [-9.15, 1.71], p = 0.64 favoring simple trapeziectomy; key pinch strength: MD 0.07 kg [-0.28, 0.43], p = 0.68 favoring trapeziectomy with LRTI). Treatment rankings from the network meta-analysis favored trapeziectomy with and without LRTI, joint replacement, and arthrodesis. Trapeziectomy with LRTI appears to be associated with fewer major complications compared with joint replacement and arthrodesis, and more minor complications compared with simple trapeziectomy. Conclusion Until further high-quality research indicates otherwise, simple trapeziectomy should be the preferred surgical modality for base of the thumb arthritis. Level of Evidence This is a Level 1 study.

&lt;p&gt;Risk Factors That Influence Surgical Decision-Making for Patients with Low-Risk Differentiated Thyroid Cancer with Tumor Diameters of 1–4 cm&lt;/p&gt;

BackgroundThere are several controversies between thyroid lobectomy and total thyroidectomy for surgical management of low-risk differentiated thyroid cancer (DTC) with a tumor diameter of 1–4 cm.Patients and MethodsIn this study, we explore the factors related to selection of type of surgical procedure for 103 low-risk DTC patients with a tumor diameter of 1–4 cm.ResultsAmong 103 low-risk DTC patients with tumor diameters of 1–4 cm, 43 patients underwent total thyroidectomy and 60 patients underwent thyroid lobectomy based on postoperative pathology. A ROC curve showed that the optimal diagnostic threshold for selecting surgical modality was a tumor diameter of 2.15 cm. For these low-risk DTC patients, the sensitivity and specificity for predicting thyroid lobectomy when tumor diameter <2.15 cm while total thyroidectomy when tumor diameter ≥2.15 cm are 46.5% and 78.3%, respectively. There were significant differences between the selection of type of surgical procedure in patient groups with 1) tumors with multiple foci group vs a single focus (P<0.05), and 2) tumor diameter of ≥2.15 cm vs <2.15 cm (P<0.05). There was no significant difference between gender and age groups (P>0.05). Multivariate analysis confirmed that tumors with multiple foci and diameter ≥2.15 cm were the primary risk factors for implementation of total thyroidectomy (P<0.05).ConclusionThe diameter and multifocal nature of low-risk DTC tumors are the primary factors related to preferred surgical modality. This study revealed that thyroid lobectomy is more applicable to patients with tumor diameter <2.15 cm and a single focus, whereas, total thyroidectomy was preferred in patients with tumor diameter ≥2.15 cm and/or multiple foci.

Plasma ablation-assisted endoscopic excision versus traditional technique of endoscopic excision of juvenile nasopharyngeal angiofibroma

BackgroundJuvenile nasopharyngeal angiofibroma is the vascular and locally aggressive tumor of the posterior nares and nasopharynx. Endoscopic excision is the preferred surgical modality in early Radkowski stages. The prime challenge is intraoperative bleeding. Literature is in favor of the use of plasma ablation to overcome surgical challenges. ObjectiveTo evaluate the effectiveness of plasma ablation technique in the surgical management of juvenile nasopharyngeal angiofibroma. Materials and methodsThe current study recruited 36 patients of clinico-radiologically diagnosed cases of primary JNA of stage I and II (Modified Radkowski). In prospective arm, 18 consecutive patients were recruited, who underwent plasma ablation assisted endoscopic excision. In retrospective arm, 18 consecutive patients who underwent excision by traditional endoscopic instruments in the past two years, were recruited. Both the groups were compared for baseline characteristics, intraoperative blood loss, duration of surgery, length of hospital stay, and recurrence rates. ResultsThe use of plasma ablation decreased overall blood loss by 338 ml (mean difference) which was not statistically significant (p = 0.26). On subgroup analysis, the use of plasma ablation significantly decreased mean blood loss (648 ml, p = 0.046) and duration of surgery (83 min, p < 0.001) in patients who underwent embolization. No statistically significant difference was noted between two groups in length of hospital stay (p = 0.36) and recurrence rates (p = 0.64). ConclusionPlasma ablation is an effective technique available to decrease blood loss and duration of surgery during endoscopic excision of post embolized stage I and II patients of JNA.

Clinical outcomes of different therapeutic modalities for rectal gastrointestinal stromal tumor: Summary of 14-year clinical experience in a single center.

The optimal treatment for gastrointestinal stromal tumor (GIST) of the rectum is controversial due to the extremely low incidence of the disease. The aim of the present study was to compare the clinical outcomes of different treatment modalities for rectal GIST by reviewing the 14-year experience in our center. Medical records of rectal GIST patients who received surgical treatment in our center between January 2004 to December 2017 were reviewed retrospectively. Overall survival (OS) and recurrence-free survival (RFS) were used as the observation endpoints. Included in this study were 71 GIST patients, including 42 patients who underwent local excision (LE) and 29 patients who underwent segmental resection (SR). There were differences in tumor size (P=0.001) and malignant risk grade (P=0.007). The LE approach achieved a lower rate of R0 resection than SR (29/42 vs.27/29, P=0.015) and shorter hospital stay (P=0.004). Preoperative imatinib mesylate (IM) therapy improved the rate of sphincter-sparing surgery for patients with tumors in the very low segment of the rectum (P=0.012) and offered better R0 resection margins (P=0.027). Multivariate analysis showed that the resection margin status (P=0.014), risk stratification (P=0.001) and IM therapy (P=0.042) were independent factors affecting RFS of rectal GIST patients but not the surgical modalities (LE vs. SR, P=0.802). Multivariate analysis showed no significant impact of these variables on OS. Selection of surgical modalities has no significant impact on the prognosis. Local excision is the preferred surgical modality for resectable rectal GIST by virtue of less injury and shorter hospital stay. IM therapy has proved to be associated with improved RFS for rectal GIST patients.

Surgeons' preferences and anxiety levels in paediatric adenotonsillectomy: European perspective.

This study assessed the preferences of surgeons regarding surgical modalities used for adenotonsillectomy, and determined anxiety levels related to the adenotonsillectomy procedure. A 10-question survey created by the authors was administered to 413 ENT specialists attending the 4th Congress of Otorhinolaryngology Head and Neck Surgery, held in October 2017 in Barcelona, Spain. Cold knife dissection was the preferred surgical modality for both adenoidectomy and tonsillectomy. Most participants reported encountering one to five patients with post-tonsillectomy bleeding throughout their entire career. The mean anxiety levels during surgery and the 10-day post-operative period were 3.39 ± 2.14 and 4.18 ± 2.63, respectively (p &lt; 0.05). There was a significant negative correlation between anxiety level and surgeon's experience (p &lt; 0.05). Cold dissection is still the preferred surgical modality for adenotonsillectomy, while both suture ligation and electrocautery are used for haemostasis. Paediatric adenotonsillectomy is likely to generate anxiety in ENT surgeons, and the possibility of secondary post-tonsillectomy bleeding increases the anxiety levels of surgeons in the post-operative period.

Mitral Valve Repair for Rheumatic Valve Disease in Children: Midterm Results and Impact of the Use of a Biodegradable Mitral Ring

Mitral valve repair for rheumatic mitral valve disease in children has become the preferred surgical modality. A mitral valve ring is frequently used in the repair. A recently introduced biodegradable ring has shown promising results and allows for growth of the native annulus. Between January 1994 and March 2006, 220 children underwent mitral valve repair for rheumatic valve disease. Mitral valve insufficiency was predominant in 198 patients (90%). Fifty-seven patients (26%) had associated aortic valve insufficiency and 51 (23%) had tricuspid valve insufficiency addressed during the same surgery. A mitral valve ring was used in 213 patients (173 Carpentier-Edwards and 40 biodegradable rings). Ninety-two percent (202 of 220) were in New York Association class III to IV. Echocardiography was performed at 6 months and thereafter once yearly. There were no hospital deaths or major postoperative morbidity. Follow-up was complete in 96% (212 of 220). One late death occurred. Mean follow-up was 76.4 months (range, 1 to 13 years). One patient (0.5%) had immediate mitral valve repair failure and required mitral valve replacement. Twelve patients (5.5%) required reoperation during follow-up. Recurrent mitral valve insufficiency/stenosis-free survival was 94.5% at 5 years and 92.7% at 10 years. Mean gradient was 5.2 +/- 1.9, 6.2 +/- 2.0, and 7.0 +/- 2.3 mm Hg, respectively, at 7 days, 6 months, and 1 year postoperatively for the Carpentier-Edwards ring and significantly lower (p < 0.001) for the biodegradable ring at 2.8 +/- 0.5, 3.1 +/- 0.7, and 3.3 +/- 0.5 mm Hg, respectively. Unchanged mean gradient during the first year was 65% (26 of 40) for the biodegradable ring and 21% (31 of 147) for the Carpentier-Edwards ring. Mitral valve repair in children with rheumatic valve disease has excellent immediate results with low operative risk and satisfactory midterm results and should therefore be the preferred treatment of choice. The use of biodegradable mitral valve ring results in a significant lower mean gradient during the first year of implantation compared with the Carpentier-Edwards ring and is available in a wide range of sizes.