Purse-string Suture Research Articles

Development of a novel endoscopic suturing simulator: validation and impact on clinical learning curve (with video)

Background and AimsEndoscopic suturing is a complex skill with broad applications. This study aims to develop and validate a novel endoscopic suturing simulator and scoring system for the pursestring suture pattern. MethodsThis was a prospective study of an endoscopic suturing simulator, which consists of a circular opening representing a dilated gastrojejunal anastomosis of Roux-en-Y gastric bypass with 12 small target holes around its circumference. Pursestring suturing is performed in a counterclockwise fashion. Time allotted is 5 minutes. Each successful bite is awarded 10 points. Participants were divided into the novice, intermediate and experienced groups. Validity evidence based on content, validity evidence based on other variables and validity evidence based on consequences of testing were assessed. Results17 subjects (3 novice, 7 intermediate and 7 experienced) participated in the study. Validity evidence based on content: The content validity index for realism, relevance and representativeness was 0.89, 1.00 and 1.00, respectively. Validity evidence based on other variables: The novice, intermediate and experienced groups scored 30.0±8.2, 57.1±28.1 and 131.2±51.7, respectively (p=0.001). Validity evidence based on consequences of testing: The simulator group required 5±5 transoral outlet reduction cases before being able to independently complete an entire pursestring, while the non-simulator group required 38±11 clinical cases (p<0.0001). ConclusionThis novel endoscopic suturing simulator appears realistic, relevant and representative of the clinical suturing experience. Additionally, it appears effective at objectively assessing suturing skills and shortening the clinical learning curve.

Sequential breast and nipple-areolar complex reconstruction after soft tissue necrosis following augmentation mastopexy: a case report

Breast augmentation mastopexy is a common procedure in cosmetic plastic surgery. Augmentation mastopexy has proven to be a relatively safe operation, but surgeons should be aware of and able to cope with disastrous complications such as soft tissue necrosis and nipple loss. The most important consideration in breast reconstruction is the recovery of breast shape and symmetry, as well as the maintenance of the shape of the nipple-areolar complex without any complications. We experienced a case of sequential breast and nipple-areolar complex reconstruction, in which the purse-string suture technique was used to repair medium-sized circular defects accompanied by nipple loss in the central area of both breasts and to preserve the shape of both breast mounds. Modified CV flaps were performed for left nipple reconstruction, and the Elsahy method and the purse-string suture technique were used to reconstruct the right nipple. Tattooing was performed on both breasts for areolar reconstruction. Through sequential reconstruction, the patient achieved satisfactory aesthetic results. In medium-sized, round defects on the central breast accompanied by nipple loss, the pursestring technique is a simple and effective reconstructive option that enables maintenance of the breast mound shape without requiring additional incision or distortion of surrounding structures.

Bi's purse-string suture: an effective method for presacral venous bleeding.

Presacral venous bleeding (PSVB) is an intractable situation during rectal mobilization. Till now, various methods for PSVB are introduced, but each of them has limitations. This article aims to introduce an effective approach for PSVB, which is created by Professor Xiaogang Bi. In the case of PSVB, a purse-string suture which highlighted each stitch penetrates periosteum of sacrum was performed around the bleeding site. After that, the branches of presacral venous plexus around the bleeding site were compressed to the sacrum when the stitches were tightened, the blood flow of the venous branches was blocked by the thread across them, the bleeding was controlled, and then, the knot was tied. From April 24th 2017 to November 6th 2022, ten patients who suffered PSVB during surgery accepted Bi's suture. With Bi's suture, all of the ten cases of PSVB were controlled effectively. Nine of ten cases were controlled immediately only by Bi's suture, one case which accompanied with blood oozing of sacrum wound was controlled by Bi's suture, bone wax, and pelvic gauze packing. Bi's suture is an effective approach for PSVB. It could be easily performed without the need of special materials.

Ovarian mucinous adenocarcinoma and false negative frozen pathology: A case report and review of the literature

Introduction: In this case report we discuss the presentation and management of a woman with a large adnexal mass. Case Report: This report describes a 32-year-old year healthy woman who presented with four months of increasing abdominal fullness. Computed tomography (CT) imaging showed a 34 cm fluid-filled left adnexal mass with few thin septations. Tumor markers were within normal limits. She strongly desired minimally invasive surgery in the setting of low concern for malignancy. A mini-laparotomy was performed, purse string sutures were placed through the cyst wall, and fluid was aspirated with minimal spillage. Her left tube and ovary were resected laparoscopically. Intraoperative frozen pathology returned as mucinous cystadenoma with some areas of atypia. Final pathology resulted with Grade 2 mucinous adenocarcinoma and she was taken back to the operating room for a surgical staging procedure. Pathology from her laparoscopic staging surgery was benign. She underwent chemotherapy with carboplatin/paclitaxel for Stage 1C1, Grade 2 mucinous adenocarcinoma of the ovary based on intra-operative spillage. Conclusion: Despite reassuring imaging and tumor markers, particularly in the setting of frozen pathology with low concern for malignancy, final pathology may indicate carcinoma. Although the accuracy of intra-operative frozen pathology is generally high, both gynecologic oncologists and non-oncologic gynecologists should be aware of the limitations of the test and counsel patients that the final pathology may be discordant. Appropriate counseling about the risk of intra-operative spillage and subsequent upstaging is of particular importance.

Preserving the Nipple Projection in Breast Reduction with the Free Nipple-Areolar Graft Technique: Purse-String Suture.

Breast reduction with the free nipple-areolar graft (FNG) technique has disadvantages such as loss of nipple projection, loss of nipple sensation, and depigmentation of the nipple-areolar complex. In this study, patients in whom a purse-string (PS) suture was used in the center of the de-epithelialized area to prevent loss of nipple projection were compared with patients who underwent the conventional method. A retrospective analysis of the patients who underwent breast reduction with the FNG was conducted in our department. Patients were divided into two groups according to the FNG placement. In the PS suture method group, a 1-cm-diameter circumferential suture was placed with a 5-0 Monocryl® (poliglecaprone 25) suture to gain a 6-mm-nipple projection. In the conventional method group, the FNG was placed directly over the de-epithelized area. Graft viability was evaluated after 3 weeks postoperatively. The final nipple projection and depigmentation were evaluated after 6 months postoperatively. The results were evaluated with statistical tests. The number of patients with the conventional method was 10, and the PS suture method was 12. There was no statistically significant difference between two groups regarding graft loss and depigmentation (p > 0.05). Nipple projection was significantly higher in the PS method group (p < 0.05). We observed that PS circumferential suture made an acceptable nipple projection compared to the conventional method in breast reduction with the FNG technique. Since the method is easy to apply and has relatively low risk, it would contribute to clinical practice. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Intrathoracic anastomosis using handsewn purse-string suturing by the double-ligation method in laparo-thoracoscopic esophagectomy

In minimally invasive esophagectomy (MIE), it is important to reduce the rate of anastomotic leakage to ensure its safety. At our institute, the double-ligation method (DLM) has been introduced to insert and fix the anvil of the circular stapler for intracorporeal circular esophagojejunostomy in gastric surgery. We adopted this method for intrathoracic anastomosis (IA) in MIE. The aim of this study was to investigate the safety of IA with DLM in MIE.In this study, 48 patients diagnosed with primary middle or lower third segment thoracic esophageal carcinoma with clinical stage I, II, III or IV disease were retrospectively evaluated. Postoperative outcomes were assessed.Among the 48 patients, 42 patients underwent laparo-thoracoscopic esophagectomy and IA using a circular stapler with the DLM. The average total operation time and thoracoscopic operation time were 433 and 229 minutes, respectively. The average purse-string suturing time was 4.7 minutes. The rates of anastomotic leakage and stenosis were 2.4% and 14.3%, respectively. The overall incidence of postoperative complications (Clavien-Dindo grade of ≥III) was 16.7%. The average postoperative stay was 16 days.The procedure of IA using a circular stapler with the DLM in MIE was safe and provided a low rate of anastomotic leakage.

Reducing anastomotic leakage in TaTME by mucosal coverage of staple lines: a pilot study with preliminary results

PurposeWe have performed a single stapled anastomosis with double purse-string sutures as a Trans anal Total Mesorectal Excision (TaTME) reconstruction for low rectal cancer. We report an attempt to control local infection and reduce anastomotic leakage (AL) at this anastomotic site.Patients and methodsFifty-one patients who underwent TaTME for low rectal cancer from April 2021 to October 2022 were included. TaTME was performed by two teams, and reconstruction was performed by anastomosis with a single stapling technique (SST). After the anastomosis was thoroughly cleaned, Z sutures were placed parallel to the staple line to suture the mucosa on the oral and anal side of the staple line and to cover the staple line circumferentially. Data on operative time, Distal Margin (DM), recurrence and postoperative complications including AL were prospectively collected.ResultsThe mean age of patients was 67 years. There were 36 males and 15 females. The overall mean operative time was 283.1 min, and the mean Distal Margin was 2.2 cm. Postoperative complications were observed in 5.9% of the patients, but no AL was observed, nor any serious complications with Clavien-Dindo ≥ 3 grade. Of the 49 cases excluding Stage 4, postoperative recurrence was observed in 2 cases (4.9%).ConclusionIn patients with lower rectal cancer who underwent TaTME, additional mucosal coverage of the anastomotic staple line by transanal manipulation after reconstruction may be associated with a reduction in the incidence of postoperative AL. Further studies including late anastomotic complications are needed.

The Outcome of Treatment in Second Branchial Cleft Anomalies: A Case Series.

Background Branchial-cleft anomalies are second only to thyroglossal duct anomalies among congenital malformations of the neck, and second branchial-cleft anomalies are the most common. These include branchial cysts, branchial sinuses, and branchial fistulas. Clinical symptoms include neck swelling and a discharging sinus or fistula opening. In a small number of cases, they can lead to major complications like abscesses or malignant changes. Surgical resection is the treatment of choice. Various approaches to resection and sclerotherapy have been tried. In this study, we present our treatment outcome with branchial cleft anomalies at a ruraltertiary medical care hospital. Objectives To document the various presentations, clinical features, and outcomes of treatment with second branchial cleft anomalies. Methods This retrospective observational study included 16 patients operated on for second branchial-cleft anomalies. A detailed medical history was elicited, and an accurate clinical examination was done. A contrast-enhanced computed tomography (CECT) scan was done in all cases. A few cases required a fistulogram. The cysts, sinuses, or fistulas were resected en bloc by a single neck crease incision. Primary closure was done in all cases. A recurrence or pharyngocutaneous fistula required axial flap reconstruction. The complications and recurrences were documented. Result There were six children and 10 adults in our study. Seven cysts, five sinuses, and four fistulas were present, of which four were iatrogenic. In seven patients, imaging could not show the entire tract. There were four fistulas from the oropharynx to a cutaneous opening in the neck. A complete resection was done for all. Two pharyngocutaneous fistulas were treated with a pectoralis major myocutaneous (PMMC) flap. Three patients had wound dehiscence postoperatively. None of the patients had neurological or vascular injuries. Conclusion Second branchial cleft anomalies can be completely excised by a single neck crease incision. Meticulous surgery results in a low recurrence or complication rate.Following complete excision, in type IVanomalies, a purse-string suture at the pharyngeal opening ensures good closure and no recurrences.

MLuq Protocol: A Proposal for the Immobilization of the White Weapon, Preservation of DNA Traces, and Its Chain of Custody.

Unprecedentedly, this article presents a useful management protocol for the workers in emergency situations assisting victims of white weapon aggressions with a dual innovation. It could presage a possible advance in the healthcare management of these patients and support important repercussions in the legal field when this type of wound is inflicted due to an aggression. The MLuq protocol has been agreed by consensus in a multidisciplinary manner including experts belonging to the state security forces (judicial and scientific Police), to the healthcare area (surgical nursing, emergency medicine, general cardiothoracic and digestive surgery, and the legal and forensic medicine area), to the legal system (a jurist specialized in the area), and to the academic sphere. It is the first paper to propose purse string sutures as a weapon immobilization technique, as well as a set of actions designed to obtain biological traces of legal interest and to preserve the chain of custody. Therefore, it is a useful tool for the health and legal personnel, and especially for the victims.

Impact of purse-string uterine suture on scar healing after a cesarean delivery: a randomized controlled trial

Uterine closure technique can affect scar healing, potentially resulting in unfavorable gynecologic and life-threatening obstetrical outcomes. Double-layer continuous unlocked suture has been demonstrated to promote optimal residual myometrial thickness. Recently, the purse-string uterine suture technique has emerged as a viable method to enhance the healing of scars. However, the current lack of randomized trials assessing the relevance of this technique warrants further investigation. This study aimed to evaluate the impact of purse-string uterine sutures on scar healing after cesarean delivery when compared with double-layer continuous unlocked suture. This was a randomized controlled trial; 126 patients with singleton pregnancies undergoing primary cesarean delivery were enrolled in 2 groups. The primary outcome was the mean residual myometrial thickness measured by saline infusion sonography 6 months after surgery by 2 sonographers blinded to uterine closure techniques. Operative time, calculated blood loss, total number of needed threads, and perioperative scar width were used for the perioperative analysis. Healing ratio and cesarean scar defect measurements were used for the 6-month analysis. There was no significant difference in terms of residual myometrial thickness (9.38±2.3 vs 8.4±3.9 mm; P=.187), blood loss (540 [146-982] vs 495 [241-903] mL; P=.815), or operative time (6.2 [5.2-7] vs 6 [5.3-7] minutes; P=.977). Achievement of purse-string uterine suture required significantly fewer threads (1 [1-1] vs 2 [1-2]; P<.001) and fewer hemostatic complementary sutures (1 [1-1] vs 1 [1-2]; P=.013). Scar width was significantly lower with purse-string uterine sutures (50 [40.5-50.5] vs 70 [60-70.5] mm; P<.0001). Purse-string uterine sutures allowed a higher healing ratio (1 [0.9-1] vs 0.84 [0.59-1]; P=.003) and significantly fewer cesarean scar defects (12% vs 35%; P=.018) compared with double-layer continuous unlocked suture. Despite resulting in no difference in residual myometrial thickness, purse-string uterine closure seems to be associated with better uterine scar healing on the basis of a higher healing ratio, and a lower rate of cesarean scar defects compared with double-layer continuous unlocked suture.

Risk factors for complications of endoscopic full-thickness resection of upper gastrointestinal submucosal tumors

Objective: To analyze the risk factors for complications of endoscopic full-thickness resection (EFTR) of upper gastrointestinal submucosal tumors (SMTs). Methods: This was a retrospective observational study. The indications for EFTR included: (1) SMTs originating from the muscularis propria layer and growing out of the cavity or infiltrating the deep part of the muscularis propria layer; (2) SMTs diameter <5 cm; and (3) tumor identified as closely adherent to the serous layer during endoscopic submucosal dissection or endoscopic mucosal resection. This study included patients with SMTs originating from the muscularis propria layer in upper digestive tract, diagnosed preoperatively by endoscopic ultrasonography or computed tomography, who were successfully treated with EFTR. Those with incomplete clinical data were excluded. The clinical data of 154 patients with upper gastrointestinal SMTs who underwent EFTR at the Department of Gastroenterology, First Affiliated Hospital of Soochow University from January 2016 to January 2022 were retrospectively analyzed. Post-EFTR complications (such as delayed perforation, delayed bleeding, and postoperative infection, including electrocoagulation syndrome) were monitored and the risk factors for them were analyzed. Results: Among the 154 study patients, 33 (21.4%) developed complications, including delayed bleeding in three (1.9%), delayed perforation in two (1.3%), and postoperative infection in 28 (18.2%). One patient with bleeding was classified as having a major complication (hospitalized for more than 10 days because of complication). According to univariate analysis, complication was associated with tumor diameter >15 mm, operation time >90 minutes, defect closure method(purse string suture), and diameter of resected specimen ≥20 mm (all P<0.05). Multivariate logistic regression analysis showed that operation time >90 minutes (OR=6.252, 95%CI: 2.530-15.446, P<0.001) and tumor diameter >15 mm (OR=4.843, 95%CI: 1.985-11.817, P=0.001) were independent risk factors for complications after EFTR in patients with upper gastrointestinal SMTs. The independent risk factors for postoperative infection in these patients were operation time>90 minutes (OR=4.993, 95%CI:1.964-12.694, P=0.001) and purse string suture (OR=7.142, 95%CI: 1.953-26.123, P=0.003). Conclusion: Patients with upper gastrointestinal SMTs undergoing EFTR with tumor diameter >15 mm or operation time >90 minutes have a significantly increased risk of postoperative complications. Postoperative monitoring is important for these patients with SMTs.

Nipple reconstruction using modified C-V flap with purse-string sutures for maintenance of long-term nipple projection

The most common concern in nipple reconstruction is the loss of long-term nipple projection. This study aimed to demonstrate a novel method of nipple reconstruction using a modified C-V flap combined with purse-string sutures in the nipple base to maintain nipple projection. From January 2018 to July 2021, patients who underwent nipple reconstruction using the novel modified C-V flap method and conventional C-V flap were retrospectively reviewed. The ratio of projection at the 3, 6, and 12-month postoperative follow-up to the initial nipple projection was calculated and compared. A total of 116 patients were included in this study, which was comprised of 41 patients in the conventional C-V flap group (conventional) and 75 patients in the modified C-V flap with purse-string sutures group (modified). The modified group showed a significantly higher ratio of nipple projection maintenance at postoperative 3 months (79.82%, conventional; 87.25%, modified; p<0.001), 6 months (68.29%, conventional; 73.18%, modified; p<0.001), and 12 months (53.98%, conventional; 60.19%, modified; p<0.001), and a significantly lower revision rate (13/75 patients, 17.33%) than the conventional group (16/41 patients, 39.02%) (p=0.009) during a mean of 17.67-month follow-up. Nipple reconstruction using a modified C-V flap with purse-string sutures in the nipple base is a safe and effective method for the maintenance of long-term nipple projection owing to the reduction and stabilization of the nipple base.

Left hemicolectomy and low anterior resection in colorectal cancer patients: Knight-griffen vs. transanal purse-string suture anastomosis with no-coil placement.

Colorectal cancer (CRC) is considered one of the most frequent neoplasms of the digestive tract with a high mortality rate. Left hemicolectomy (LC) and low anterior resection (LAR) with minimally invasive laparoscopic and robotic approaches or with the open technique are the gold standard curative treatment. Seventy-seven patients diagnosed with CRC were recruited between September 2017 and September 2021. All patients underwent a preoperative staging with a full-body CT scan. The goal of this study was to compare both types of surgeries, LC-LAR LS with Knight-Griffen colorectal anastomosis and LC-LAR open with Trans-Anal Purse-String Suture Anastomosis (the TAPSSA group), by positioning a No-Coil transanal tube (SapiMed Spa, Alessandria, Italy), in terms of postoperative complications such as prolonged postoperative ileus (PPOI), anastomotic leak (AL), postoperative ileus (POI), and hospital stay. The patients were divided into two groups: the first with 39 patients who underwent LC and LAR in LS with Knight-Griffen anastomosis (Knight-Griffen group) and the second with 38 patients who underwent LC and LAR by the open technique with the TAPSSA group. Only one patient who underwent the open technique suffered AL. POI was 3.76 ± 1.7 days in the TAPSSA group and 3.07 ± 1.3 days in the Knight-Griffen group. There were no statistically significant differences in terms of AL and POI between the two different groups. The important point that preliminarily emerged from this retrospective study was that the two different techniques showed similarities in terms of AL and POI, and therefore, all the advantages reported in the previous studies pertaining to No-Coil also hold good in this study regardless of the surgical technique used. However, randomized controlled trials are needed to confirm these findings.

Laparoscopic Multiport Inguinal Hernia Repair in a Male Infant

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

MP65-03 ASSESSMENT OF UROSTOMY PARASTOMAL HERNIATION FORCES AND PREVENTION STRATEGIES

You have accessJournal of UrologyCME1 Apr 2023MP65-03 ASSESSMENT OF UROSTOMY PARASTOMAL HERNIATION FORCES AND PREVENTION STRATEGIES Diboro Kanabolo, Adam Maxwell, Yashwanth Nanda Kumar, Ekaterina Kuznetsova, and George Schade Diboro KanaboloDiboro Kanabolo More articles by this author , Adam MaxwellAdam Maxwell More articles by this author , Yashwanth Nanda KumarYashwanth Nanda Kumar More articles by this author , Ekaterina KuznetsovaEkaterina Kuznetsova More articles by this author , and George SchadeGeorge Schade More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003323.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Approximately 10,000 patients undergo cystectomy with ileal conduit diversion annually in the USA, of which∼50% will subsequently develop a parastomal hernia (PSH) at 2 years. Despite this, no well-established “best” practice for stoma creation exists. Due to the knowledge gap between urostomy surgical factors and abdominal wall forces, we developed a silicone and ex-vivo porcine fascia-based model for study. Our objective was to measure the relationship between incision size/type/material and axial tension force (ATF) as a surrogate for herniation force. This model was then used to evaluate a clinically applicable prevention strategy. METHODS: See system in Fig. 1a. Using incisions (linear, cruciate, circular) ranging from 1 to 3 cm (0.5cm increments) in 0.5mm silicone sheets, a dynamometer was hooked to a Foley catheter at the drainage aperture. Balloons were hydrated to 125% incision dimension. Upward ATF was recorded until balloon herniation and repeated up to N=5 membranes/size. Clinically applicable sized fascia was then used. To test force with suture, 4-0 Nylon purse string suture 1.5mm from incision edge were used (1b). A plastic tab 10% of incision diameter was laid while tying suture to prevent incisional constriction. RESULTS: The silicone ATF for herniation varied widely by incision type (Range 2.36 – 35.05 N). Linear ATF was highest, matched for size. Cruciate ATF was significantly higher than circular for each size. 3 cm incisions in ex vivo porcine fascia (Fig. 2) performed similarly. Suture reinforcement significantly raised herniation ATF for all incision types in both silicone and fascia. For example, for 3 cm cruciate, suture increased ATF 2.4-fold in silicone (p=0.008) and 3.3-fold in fascia (p=0.0001, Fig. 2). CONCLUSIONS: This ex-vivo study suggests incision type, size, and suture reinforcement have predictable influences on ATF for herniation. En-bloc porcine and cadaveric human studies are underway to assessing these factors in more clinically optimized models. If confirmed, these data may be used to standardize urostomy creation, reducing PSH risk. Source of Funding: American Urology Association, Urology Care Foundation Research Award © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e890 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Diboro Kanabolo More articles by this author Adam Maxwell More articles by this author Yashwanth Nanda Kumar More articles by this author Ekaterina Kuznetsova More articles by this author George Schade More articles by this author Expand All Advertisement PDF downloadLoading ...

Rectal Pocket Syndrome: A Symptomatic Rectal Pseudodiverticula as a Long-Term Complication of Failed Purse-String Suture During Stapled Hemorrhoidopexy

Abstract Short- and long-term complications of stapled hemorrhoidopexy have been extensively discussed during the popularization of the technique, with set complications remarkably decreasing with the progress of learning curves and improvements in the technique. We describe the management of a 58-year-old woman with a history of stapled hemorrhoidopexy who presented with proctalgia and recurrent tenesmus 12 months after the intervention. A 4-cm diverticulum in the lower rectum with fecal material inside was evidenced without a fistula. A transanal diverticulectomy was performed with primary repair of the rectal wall, with the postoperative disappearance of the symptoms. Iatrogenic rectal pseudodiverticul is an infrequent complication due to areas of focal weakness along the rectal wall after failing to complete resection of the mucosa at the circumference of the anastomosis or ineffective stapling of the entire circumference.

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Automatic purse-string suture skill assessment in transanal total mesorectal excision using deep learning-based video analysis.

Purse-string suture in transanal total mesorectal excision is a key procedural step. The aims of this study were to develop an automatic skill assessment system for purse-string suture in transanal total mesorectal excision using deep learning and to evaluate the reliability of the score output from the proposed system. Purse-string suturing extracted from consecutive transanal total mesorectal excision videos was manually scored using a performance rubric scale and computed into a deep learning model as training data. Deep learning-based image regression analysis was performed, and the purse-string suture skill scores predicted by the trained deep learning model (artificial intelligence score) were output as continuous variables. The outcomes of interest were the correlation, assessed using Spearman's rank correlation coefficient, between the artificial intelligence score and the manual score, purse-string suture time, and surgeon's experience. Forty-five videos obtained from five surgeons were evaluated. The mean(s.d.) total manual score was 9.2(2.7) points, the mean(s.d.) total artificial intelligence score was 10.2(3.9) points, and the mean(s.d.) absolute error between the artificial intelligence and manual scores was 0.42(0.39). Further, the artificial intelligence score significantly correlated with the purse-string suture time (correlation coefficient = -0.728) and surgeon's experience (P< 0.001). An automatic purse-string suture skill assessment system using deep learning-based video analysis was shown to be feasible, and the results indicated that the artificial intelligence score was reliable. This application could be expanded to other endoscopic surgeries and procedures.

Abstract Number ‐ 105: Development of Non‐Surgical Intracranial Access to the Subdural Space for Theranostic Applications in Neurology

Introduction The objective of this study was to test the hypothesis thattrans‐duralvenous sinus (tDVS)puncture from within the Superior Sagittal Sinus (SSS) is feasible. Furthermore, we determine the feasibility of accessing extravascular intracranial spaces overlying the cortex using an endovascular Inside‐Out (‘I/O’) tDVS. Aims: 1.Characterize puncture of the SSS using different size profiles and perform force measurements on benchtop and ex‐vivo models. 2.Identify the system requirements for endoluminal opposition to mediate controlled tDVSpenetration. 3.Demonstrate a system capable of tDVSpenetration and subdural‐meningeal access over the cortical convexity. Methods Silicone tube and 3D printed Superior Sagittal Sinus models were developed to assess different systems. Various re‐entry catheters (Cordis Outback, Philips Pioneer, BS Stingray LP CTO), as well as a modified construct (comprised of a 5Fr angio catheter, a BS OffroadLancet, and a distal‐end‐cut 0.014” microguidewire), were each tested on silicone tube models. To provide endoluminal apposition for controlledtDVSpenetration, various stents, stentrievers, non‐compliant balloon and compliant balloon catheters were assessed in conjunction with penetrator devices on tubular and ex‐vivo cadaveric models. To measure the force of various penetrator devices, a vector force gauge was used (3 trials by 2 independent operators). The Right Internal Jugular Vein access in a human cadaver was obtained by cut‐down and a purse string suture. Balloon microcatheters were advanced into the SSS under fluoroscopy. SSS catheterization with re‐entry devices required transcranial burr hole access due to inability to advance these beyond the jugular‐sigmoid junction. Results The Cordis Outback Re‐Entry device abuttedendoluminallyby a compliant balloon (Stryker Transform) most reliably enabled tDVSpuncture on ex‐vivo specimens (Figure 1). Only the compliant balloon provided adequate endoluminal radial support for penetrator deployment on silicon tube models, as well as enabled repositioning. The modified construct was also successful in penetrating the DVS, but required extensive manual manipulation for optimal positioning and apposition. The other support devices resulted either in kickback or insufficient radial support. In the cadaver, The Outback device markers were oriented to penetrate the SSS in a para‐sagittal trajectory after inflating the complaint balloon. The 22G cannula was deployed, and under fluoroscopy, an exchange‐lengthmicroguidewirewas advanced through the Outback and into subdural‐meningeal space. The Outback was then exchanged for a 0.021” microcatheter. Once in the subdural‐meningeal space, themicroguidewirewas withdrawn and contrast injections were performed to assess the space catheterized, which was confirmed as subdural (Figure 2). Conclusions •Controlled tDVS penetration from an endovascular locationis feasible with minimal force using a complaint endoluminal support structure. •Catheter access beneath the intracranial subdural meningeal space overlying the cortex may represent a viable route fortheranosticneurologic applications. •An in‐vivol study is needed to establish the feasibility and safety of tDVS access to the cortical surface.

Comparing Outcomes of Single-Incision Laparoscopic Herniorrhaphy in Newborns and Infants.

As surgical techniques progress, laparoscopic herniorrhaphy is now performed more often in premature babies. The aim of this study was to analyze the outcomes of newborns and infants who underwent single-incision laparoscopic herniorrhaphy (SILH) at our center. We retrospectively reviewed patients younger than 12 months old who received SILH at our department from 2016 to 2020. SILH involved a 5 mm 30-degree scope and 3 mm instruments with a 3-0 Silk purse-string intracorporeal suture for closure of the internal ring. At the time of surgery, Group 1 newborns, whose corrected age was 2 months and below, were compared to the Group 2 infants, whose age was above 2 months. We assessed the patients' characteristics, anesthesia, surgical data, and complications. A total of 197 patients were included (114 newborns in Group 1 and 83 infants in Group 2). The mean age and body weight in Group 1 were 1.2 months and 3.8 kg, respectively, whereas in Group 2, they were 3.2 months and 6.7 kg, respectively. There were no significant differences in operative time (Group 1 = 34.1 min vs. Group 2 = 32.3 min, p = 0.26), anesthetic time (Group 1 = 80.0 min vs. Group 2 = 76.3 min, p = 0.07), length of hospitalization (Group 1 = 2.3 days vs. Group 2 = 2.4 days, p = 0.88), postoperative complications including omphalitis (Group 1 = 5.3% vs. Group 2 = 1.2%, p = 0.13), wound infection (Group 1 = 0.9% vs. Group 2 = 1.2%, p = 0.81), and hydrocele (Group 1 = 0.35% vs. Group 2 = 8.4%, p = 0.14). No recurrence, testicular ascent or atrophy, or mortality was observed in either group during the 2-year follow-up period. Single-incision laparoscopic herniorrhaphy is a safe and effective operation for inguinal hernia repair in infants, even those with prematurity, lower body weight at the time of surgery, or cardiac and/or pulmonary comorbidities. Comparable results revealed no significant differences in perioperative complications despite younger ages and lower body weights.