Open Repair Research Articles

Enhanced view totally extraperitoneal approach: The best available option for recurrent incisional hernias following previous laparoscopic intraperitoneal onlay mesh plus repairs.

The available options for recurrent incisional hernias (RIH) following previous laparoscopic intraperitoneal onlay mesh (IPOM) plus were open onlay repair, open Rives-Stoppa (RS), laparoscopic enhanced view totally extraperitoneal-RS (ETEP-RS) and laparoscopic subcutaneous onlay mesh repair. Majority of these RIH were managed by open onlay mesh repairs or laparoscopic Redo IPOM plus. There are not much data available in the literature on the ETEP approach for RIH following previous IPOM plus with the placement of mesh in the retrorectus space. In this article, I would like to share technical aspects, challenges faced and tips to overcome these challenges of performing ETEP for RIH following previous IPOM plus repairs.

Acute Achilles Tendon Ruptures: An Update on Current Management Strategies

Acute rupture of the Achilles tendon is a frequently encountered injury that occurs most commonly in people who participate in recreational athletics into their thirties and forties. For many years, the injury has been treated either nonsurgically or surgically using a standard open approach. More recently, a variety of new surgical techniques have emerged in the literature aiming to improve surgical outcomes while decreasing the potential complications associated with standard open repair. Nonsurgical treatment plans using early weight bearing and accelerated functional rehabilitation have also proven to be excellent management options. Achilles rupture treatment plans can include the use of orthobiologics, such as platelet-rich plasma, with mixed results. Accelerated functional rehabilitation protocols have shown to improve patient outcomes, whether used in conjunction with surgery or nonsurgical management modalities, and reduce the disparity between the injured tendon and the native Achilles.

Predictive Accuracy of C-reactive Protein as an Early Indicator of Leakage After Anastomosis and Primary Repair in Gastrointestinal Surgery.

Background Anastomotic leakage after gastrointestinal surgery is a significant postoperative complication that leads to increased morbidity and mortality. C-reactive protein (CRP) has been used previously as a predictive marker of anastomotic leakage in gastrointestinal surgeries. Its short half-life makes it a reliable marker for postoperative complications, rapidly returning to normal values as the patient recovers. We conducted this study to evaluate the predictive accuracy of serum CRP levels in predicting anastomotic leaks in patients undergoing gastrointestinal repair surgeries. Methods Ninety-six gastrointestinal surgeries involving anastomoses and primary repairs were included in the study. CRP was taken serially from postoperative days (POD) 1 to 7. Patients were divided into two groups based on postoperative outcomes: leakage and non-leakage. The receiver operating characteristic (ROC) curve of CRP levels with leak and mortality was plotted to find a threshold value for leak and mortality. Results Out of 96 patients included in the study, Group B (non-leakage) consisted of 78 patients (81.3%), while Group A (leakage) comprised 18 patients (18.7%). ROC analysis identified a CRP cutoff of 127 mg/L on POD 5, with high sensitivity (80%) and high specificity (80%) indicating a high likelihood of leakage above this threshold. Conclusion This study underscores the importance of monitoring CRP levels in the postoperative period, particularly on POD 5, as a non-invasive and cost-effective tool for the early detection of anastomotic leaks.

Predictors of Mortality in Ruptured Abdominal Aortic Aneurysms.

Introduction The outcome of a ruptured abdominal aortic aneurysm (AAA) without any interventions is close to uniformly fatal. The Society for Vascular Surgery suggests a door-to-intervention time of less than 90 minutes in a patient with a ruptured AAA. Admission factorsassociated with poor outcomes in ruptured AAAs include hypotension, renal insufficiency, severe anemia, advanced age, and cardiac arrest. Patients who are particularly at high risk for open AAA repair may be candidates for endovascular repair, which may decrease mortality. This study aimed to assess the relationship between systolic blood pressure (SBP) and serum bicarbonate levels in predicting mortality in patients with ruptured AAAs. Methods This retrospective study was performed using the United States Collaborative Network of 57 academic medical centers/healthcare organizations in the TriNetX database. A total of 4,226 patients with ruptured AAAs were identified. Patients were categorized based on SBP of ≤90 mmHg, any SBP, or >90 mmHgand further stratified by bicarbonate levels. Rounded cutoffs of the bicarbonate ranges (<10, 10.01-15; 15.01-20, >20.01) were chosen for interpretative purposes. Mortality outcome was assessed within 90 days after presentation for the ruptured AAA. Results After exclusions, 4,174 patients presented with ruptured AAA between September 30, 2003, and September 30, 2023, in the database. Overall, 90-day mortality in any SPB cohort was 28%. Patients who presented with a ruptured AAA with an SBP ≤ 90 had a 46.3% mortality. Those who presented with a SBP > 90 had a 20.1% mortality. Additionally, as bicarbonate levels decreased, mortality increased within each SBP group. Conclusions Early recognition and intervention are critical for survival in patients with ruptured AAAs. Metabolic acidosis is an important marker of the severity of hemorrhage in these patients. In this large cohort study of ruptured AAAs, mortality increases significantly with hypotension and metabolic acidosis, represented by lower bicarbonate levels. Abnormalities in the serum bicarbonate may be seen before severe changes invital signs in hemorrhaging patients. Early recognition of metabolic acidosis may lead to earlier life-saving interventions in patients with ruptured AAAs.

ANALYZING THE RELATIONSHIP AMONG CLINICAL SYMPTOMS, X-RAY RESULTS, AND CARTILAGE WEAR PATTERNS IN KNEE OSTEOARTHRITIS USING T2 MAPPING MRI

Objectives: Osteoarthritis (OA) is a condition that causes joint pain, varying degrees of functional limitations, and a decrease in overall quality of life. The purpose of this study was to examine the progression of cartilage degeneration in knees affected by symptomatic OA and determine its relationship with X-ray and T2 map MRI findings. Methods: This study was conducted at a Tertiary Care Teaching Institute in India and involved 40 patients. It was an observational type of study. For our assessment, we utilized the Western Ontario and McMaster University (WOMAC) osteoarthrosis index to evaluate function, quality of life, and joint pain. Medical imaging technique A standing AP view of the affected knee joint was taken using plain radiographs. Once the X-rays were obtained, they were graded using the Kellgren–Lawrence Classification, which ranges from 0 to 4 grades. Results: Out of the total patients, 6.0% were &lt;40 years old, 21.2% were between 41 and 50 years old, 27.2% were between 51 and 60 years old, 39.3% were between 61 and 70 years old, and 6.0% were above 70 years old. In this study, there were 21 females (63.6%) and 12 males (36.4%). In this study, the researchers found that there was no distinction between the sides of the limb affected. Both the left and right sides were involved in 13 cases each, accounting for 39.39% of the total cases. In addition, 7 cases, or 21.21%, reported experiencing bilateral knee pain. Merchant grade reported that out of the knees examined, 17.5% had Grade 0, 45% had Grade 1, 27.5% had Grade 2, 10% had Grade 3, and none had Grade 4. Conclusion: The findings of this study suggest that T2 map MRI has the ability to accurately measure abnormal cartilage changes in conditions that affect the mechanical properties of the knee joint. It is crucial to have non-invasive methods that can assess early cartilage matrix changes. These methods are important for initiating early treatment, monitoring disease progression, planning operative procedures, and following up on operative cartilage repair.

Comparative Study between Open and Laproscopic Inguinal Hernia Repair

Comparative Study between Open and Laproscopic Inguinal Hernia Repair

Use of Branched EVAR in Treatment of Juxtarenal Aortic Aneurysm and Essential Accessory Renal Artery: Another Tool on the Shelf? A Case Report.

We present the case of a 58-year-old male patient referred to our department from a smaller facility for further evaluation and treatment strategy regarding the choice between open or endovascular surgery. The patient was diagnosed with a 6cm asymptomatic juxtarenal aortic aneurysm and a 5mm diameter accessory renal artery (ARA) supplying the lower half of left kidney. Further diagnostic assessments indicated that the left ARA was perfusing over 40% of the left kidney. Given the patient's significant pre-existing medical conditions and elevated perioperative risk, the decision was made to proceed with minimally invasive endovascular surgery using a custom-made 5-branches stent graft (BEVAR). In the early postoperative period, the patient reported left flank pain. A subsequent CT scan identified a partial infarction in the left kidney due to the occlusion of an early small branch from the upper left renal artery. However, laboratory results showed no significant change in renal function compared to preoperative values. The patient was discharged 6 days post-surgery, with no additional complications observed during the early postoperative period. This case report demonstrates that BEVAR is acceptable technique with satisfactory early postoperative outcomes for treating juxtarenal aortic aneurysms with an accessory renal artery in patients who are high-risk candidates for open repair and anatomically unsuitable for FEVAR or Ch-EVAR procedures.

Laparoscopic versus open repair for peptic ulcer perforation: a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials. Time to conclude!

The aim of this study was to investigate comparative outcomes of laparoscopic and open repair for peptic ulcer perforation (PUP). A PRISMA-compliant systematic review with a PROSPERO-registered protocol (registration number CRD42024529286) was conducted. All randomised controlled trials (RCTs) involving PUP patients managed by laparoscopic or open repair were identified and their risk of bias assessed. Outcome syntheses for perioperative mortality and morbidities, need for reoperation, procedure time and length of hospital stay were conducted using random-effects modelling to calculate risk ratios (RR) or mean difference (MD) with 95% confidence intervals (CI). Nine RCTs met the inclusion criteria, enrolling 670 patients of whom 317 were randomised to receive laparoscopic surgery and 353 were managed with open surgery. Laparoscopic repair of PUP significantly reduced mortality (RR 0.37, p = 0.03), total complications (RR 0.57, p = 0.0009), ileus (RR 0.43, p = 0.04), wound complications (RR 0.36, p < 0.0001) and length of hospital stay (MD -2.37, p = 0.0003) compared with the open approach. There were no significant differences in rate of postoperative leak (RR 2.00, 95% CI 0.74-5.41, p = 0.17), abdominal collection (RR 1.19, 95% CI 0.46-3.07, p = 0.72), sepsis (RR 1.17, 95% CI 0.39-3.52, p = 0.65), respiratory complications (RR 0.68, 95% CI 0.32-1.46, p = 0.32), reoperation (RR 1.74, 95% CI 0.57-5.30, p = 0.33) and operating time (MD 15.31, 95% CI -4.86 to 35.47, p = 0.14) between the two groups. Laparoscopic repair of PUP is associated with significantly lower mortality and morbidity and shorter length of stay compared with the open approach. The laparoscopic approach should be the management of choice subject to the existence of laparoscopic expertise.

Analysis of the therapeutic effect of right mid-axillary approach in the surgical treatment of ASD and VSD in children

BackgroundTo compare the therapeutic effects of right vertical infra-axillary thoracotomy (RVIAT) and Standard Median Sternotomy (SMS) in the repair of atrial septal defect (ASD) and ventricular septal defect (VSD), and to evaluate the safety and effectiveness of right subaxillary incision technique in the surgical treatment of common congenital heart disease (CHD) in children.MethodsData of children diagnosed with ASD repair or VSD repair at our center from September 2019 to September 2022 were collected. Based on propensity score matching, 214 children (107 in the RVIAT group and 107 in the SMS group) who completed ASD repair surgery and 242 children (121 in the RVIAT group and 121 in the SMS group) who completed VSD repair surgery were selected for the study. The perioperative and follow-up data of the two surgical approaches were compared to evaluate clinical efficacy.ResultsThere was no statistically significant difference (p > 0.05) between the two surgical approaches in terms of surgical time, aortic occlusion time, total amount of ultrafiltration fluid, ICU stay time, and hospital stay; The intraoperative blood loss and total postoperative drainage fluid in the RVIAT group were lower than those in the SMS group (p < 0.05); The incidence of postoperative thoracic deformities in the SMS group is higher than that in the RVIAT group.ConclusionThe safety and effectiveness of the two approaches are similar, but RVIAT has less intraoperative bleeding, less postoperative drainage fluid and tube time, and better concealment and cosmetic effects, which is worthy of further clinical promotion and application.

Tabular review of contemporary fenestrated-branched endovascular aortic repair experiences for treatment of thoracoabdominal aortic aneurysms.

Repair of thoracoabdominal aortic aneurysms (TAAAs) represents a technical challenge regardless of which technique is used. Open surgical repair (OSR) is the time-tested option against which novel techniques must be compared and it is still considered the gold standard option for younger, fit patients with heritable aortic diseases. Endovascular repair offers a less-invasive alternative in patients with suitable anatomy. This article aims to present a tabular review of the contemporary published data on endovascular repair of TAAAs using fenestrated-branched techniques. The published literature for single-center and multicenter studies evaluating the outcomes of FB-EVAR for TAAAs was searched using MEDLINE and Embase databases. Studies published between January 1st 2010 and July 11th 2024, in the English language which provided data on FB-EVAR of TAAAs with more than fifty reported cases were included. The average patient age at time of repair was 71 years old with majority of males (65.5%). Most patients presented with a Crawford Extent II TAAAs (21.6%), followed by Extent III (21.2%). Early mortality was 4.9% for the entire cohort. The most prevalent adverse event was acute kidney injury (9.4%), followed by spinal cord injury (8.0%). FB-EVAR of TAAAs continues to evolve. Pooled analysis of early mortality and morbidity is lower in this tabular review than historical outcomes of open TAAA repair.

TAPP versus lichtenstein techniques for bilateral inguinal hernia repair: A systematic review and meta-analysis.

Inguinal hernia repair is one of the most common surgical procedures performed worldwide. However, very few studies report data on the laparoscopic advantages of bilateral inguinal hernia (BIH) repair over the open approach. Therefore, this meta-analysis was conducted to compare the effectiveness of the laparoscopic trans-abdominal pre-peritoneal (TAPP) technique with the open Lichtenstein repair technique (OLR) for the repair of BIH. A detailed literature search was conducted on PubMed, Google Scholar, and Cochrane Library for comparative studies between TAPP and OLR techniques for repair of BIH. RevMan Version 5.4 was used for data analysis. The Inverse Variance statistical method was used to analyze the primary outcomes and the Mantel-Haenszel statistical method was used to analyze the secondary outcomes. The effect measure was reported as a Risk Ratio. There was no significant difference in recurrence between the two groups. A significant difference was seen in duration of post-operative hospital stay, operative time, pain score on VAS criteria on post-operative Day 1, pain score on VAS criteria on post-operative Day 7, and complications, all in the favor of TAPP except for operative time which was in the favor of OLR. TAPP was found to be superior to OLR in terms of duration of post-operative hospital stay, pain scores on VAS criteria on post-operative days 1 and 7, and complications, whereas OLR was found superior only in terms of operative time. For recurrence, there was no significant difference between the two groups.

Changes in shoulder function and muscle strength following rehabilitation exercise program in male patients with forward shoulder posture undergoing rotator cuff repair

BackgroundAbnormal posture is known to affect the efficacy of exercise therapy for musculoskeletal diseases. However, no studies to date have examined the effect of exercise programs should take into account the posture of the upper body in patients with rotator cuff disease. This study aimed to assess how rotator cuff and corrective exercises impact shoulder function and muscle strength post-arthroscopic rotator cuff repair surgery, providing tailored rehabilitation programs for patients with forward posture.MethodsNinety male patients who underwent arthroscopic rotator cuff repair participated in this study. The patients were randomly divided into three groups corrective exercise group (CEG, n = 29), rotator cuff exercise group (REG, n = 27), and control group (CG, n = 28). Each group was instructed to apply different exercise programs to correct posture and enhance rotator cuff strength. All patients were checked by the American Shoulder and Elbow Surgeons (ASES) score, Constant score and muscle strength, and range of motion preoperatively and postoperatively at 6 months and 1 year.ResultsASES shoulder function scores showed significant difference between the three groups (p = 0.002, F = 7.03), indicating that the corrective exercise program was more beneficial than rotator cuff exercises (p = 0.009, F = 3.78). A significant intergroup difference in mean Constant score was also noted (p = 0.025, F = 3.86), while a statistically significant interaction between time and group was observed (p = 0.032, F = 2.96).ConclusionsThese results suggested that a corrective exercise program can improve shoulder muscle strength and function after rotator cuff repair in male patients with a forward shoulder posture.

Tethered cord prevalence among patients with prenatal or postnatal myelomeningocele repair.

Myelomeningocele (MMC) is a severe form of spina bifida characterized by spinal cord extrusion into a cerebrospinal fluid (CSF) filled sac which may lead to lifelong disability. Repair of these lesions have classically occurred shortly after birth, but more recently, prenatal myelomeningocele repair techniques have been elucidated. This study aimed to investigate the outcome of surgery, particularly with subsequent spinal cord tethering, in patients with prenatal myelomeningocele closure and those with postnatal repair surgery. In this retrospective study which assessed patients from April 2002 to April 2020, the data of 18 total patients with MMC were reviewed. Nine patients from each group were included, closed prenatally or postnatally, respectively. Demographic information including age and sex, birth week, infant comorbidities, presence of dermoid or lipoma, cutaneous stigmata, total number and timing of detethering procedures, presence of Chiari malformation, and need for VPS was obtained. Eighteen patients including nine infants closed prenatally and nine infants with myelomeningoceles closed postnatally were reviewed. The mean age was 4 ± 3years and 6.22 ± 2.4 in prenatal and postnatal retrospectively. There was a significant relationship between the number of detethering procedures (p-value = 0.03) and the need for a ventriculoperitoneal shunt (VPS) (p-value = 0.01) between the groups, with the prenatal closure group having lower rates of each. There was no significant difference between the groups in regard to the mean age at the detethering procedure (p = 0.4), sex (p = 0.09), birth week (p = 0.8), comorbidities (p = 0.8), presence of intraspinal dermoid or lipoma (p = 0.09), presence of cutaneous stigma (p = 0.08), Chiari (p = 0.6), fatty filum (p = 0.08), syrinx (p = 0.4), bone anomaly (p = 0.4), and spina bifida neurological scale (p = 0.66). There was a significant relationship between the two groups in terms of the number of detethering procedures, and the need for VPS. Our data represents a possible difference in the need for detethering surgeries and ventriculoperitoneal shunt placements between patients with prenatal and postnatal myelomeningocele closures.

Comparison of Open and Endovascular Repair of Complex Abdominal Aortic Aneurysms

To compare perioperative and 5-year outcomes following endovascular (FEVAR) and open repair (OAR) of complex abdominal aortic aneurysms (cAAA) in males and females separately, given the known sex related differences in perioperative outcomes. We studied all elective cAAA repairs between 2014-2019 in the Vascular Implant Surveillance and Interventional Outcomes Network (VISION) registry. We stratified patients based on sex. We calculated propensity scores for assignment to either OAR or FEVAR. Covariates including age, race, diameter, baseline comorbidities, proximal extent of repair, annual center volumes, and annual surgeon volumes were introduced into the model for estimating propensity scores. Within matched cohorts, perioperative outcomes and 5-year outcomes (mortality, reinterventions, and ruptures) were evaluated using multivariable logistic and Cox regression models. We identified 2,825 patients of whom 29% were female. Within both the sexes, OAR was more commonly performed (OAR vs FEVAR: males: 53% vs 47%; females: 63% vs 37%). After matching, among males (n=1326), FEVAR was associated with lower perioperative mortality (FEVAR vs OAR: 2.3% vs 5.1%; p<.001). However, FEVAR was associated with comparable 5-year mortality (38% vs 28%; hazard ratio (HR) 1.2 [0.92-1.4]; p=.22) and a higher hazard of 5-year reintervention (19% vs 3.7%; aHR: 4.5 [2.6-7.6], p<.001). Among females (n=456), FEVAR and OAR showed similar perioperative mortality (8.3% vs 7.0%; p=.73). At 5 years, FEVAR was associated with higher hazards of mortality (43% vs 32%; aHR: 1.5 [1.03-2.2], p=.034) and reintervention (20% vs 3.0%; aHR: 4.8 [2.1-11], p<.001) compared with OAR. Among males, FEVAR was associated with favorable perioperative outcomes compared with OAR, though these advantages attenuate over time. However, among females, FEVAR was associated with similar perioperative outcomes, eventually leading to higher reinterventions and possibly higher mortality within 5 years. Future efforts should focus on determining the factors associated with these sex disparities to improve outcomes following FEVAR in females. Based on current evidence, females undergoing elective cAAA repair should be selected with due caution, especially for endovascular repair.

The Relationship Between Peri-Operative Systemic Inflammation and Survival in Patients With Abdominal Aortic Aneurysm

An association between pre-operative markers of systemic inflammation and inferior mortality following AAA repair has been observed. The prognostic value of the post-operative inflammatory response remains unreported in patients with AAA. The present study aimed to describe the association between the peri-operative inflammatory response & mortality in patients undergoing endovascular aneurysm repair (EVAR) and open surgical repair (OSR) for infrarenal AAA. Consecutive patients undergoing either emergency (EVAR or OSR) or elective (OSR) intervention for infrarenal AAA were retrospectively recruited from 3 centres. Pre-operative systemic inflammation was assessed using the modified Glasgow Prognostic Score (mGPS). Post-operative day 3 CRP (≤ 300mg/L, > 300mg/L) was chosen as the covariate of interest. The primary outcome was thirty-day mortality in the emergency cohort and twelve-month mortality in the elective cohort. There were 167 emergency cases (120 (72%) OSR) and 207 elective (207 (100%) OSR) cases, with a median (IQR) follow-up of 85 (52) months in the emergency cohort and 63 (57) months in the elective cohort. There were 56% vs. 44% of patients in the emergency cohort day 3 CRP ≤300mg/l vs. >300mg/L compared with 82% vs. 18% of patients in the elective cohort (p < 0.001). On univariate binary logistic regression analyses in the emergency cohort, open repair (p < 0.05), pre-operative mGPS 2 (p < 0.05), post-operative mesenteric ischaemia (p < 0.01), and day 3 post-operative CRP > 300mg/L (p < 0.05) were associated with increased odds of thirty-day mortality. On multivariate binary logistic regression analyses, only pre-operative mGPS 2 (OR 2.11, 95% CI 1.12 - 3.98, p < 0.05) retained independent association with thirty-day mortality. In the elective cohort, mean (95% CI) survival in the day 3 CRP ≤300mg/l vs. >300mg/L was 112.0 (101.8 - 122.2) months vs. 67.2 (54.1 - 80.2) months (p < 0.001). On univariate binary logistic regression analyses in the elective cohort, age ≥ 75 (p < 0.05), ischaemic heart disease (p < 0.05), and day 3 post-operative CRP > 300mg/L (p < 0.001) were associated with increased odds of twelve-month mortality. On multivariate binary logistic regression analyses, both age ≥ 75 (OR 5.15, 95% CI 1.25 - 21.30, p < 0.05) and day 3 post-operative CRP > 300mg/L (OR 15.68, 95% CI 3.61 - 68.15, p < 0.001) retained independent association with twelve-month mortality. Pre- and post-operative markers of systemic inflammation were independently associated with inferior survival following emergency and elective repair of AAA respectively. Further investigation of the peri-operative systemic inflammatory response is warranted in this patient group, with a particular focus on identifying targets for intervention.

Long-Term Outcomes of Elective Endovascular versus Open Repair of Popliteal Artery Aneurysms in the VISION Database

IntroductionThe best modality for elective popliteal artery aneurysm repair (PAR) remains controversial. Most single center studies suggest open popliteal aneurysm repair (OPAR) is more durable than endovascular (EPAR), but large randomized multicenter studies are lacking. This study compares long-term outcomes of EPAR and OPAR in the VQI-VISION database. MethodsVascular Quality Initiative (VQI) Medicare-linked VISION database (2010-2019) for peripheral vascular interventions and infrainguinal bypass were reviewed for elective PAR. Patients undergoing OPAR and EPAR were propensity-matched to compare outcomes. ResultsThere were 1,159 PAA repairs (65.1% open). EPAR patients were older (77 vs 73 years, p<0.001) and more likely to be on P2Y12 inhibitors (26.5% vs 17.0%, p<0.001). After matching, there were 396 patients in each group with similar baseline characteristics. EPAR patients were more likely to be discharged home (87.6% vs 48.5%, p<0.001) and have shorter hospital length-of-stay (1 vs 3 days, p<0.001). Kaplan-Meier curves showed no difference in mortality, reintervention, or major amputation at 1, 3, and 5 years. Cox proportional hazards regression showed no significant association between revascularization strategy and mortality, reintervention, or major amputation. Subgroup analysis of patients undergoing OPAR with great saphenous vein (GSV) bypass compared to EPAR showed that OPAR with GSV bypass was associated with lower mortality without difference in reintervention or major amputation. ConclusionElective EPAR is durable and comparable to OPAR in terms of limb outcomes, even when GSV is used as conduit. However, bypass with GSV was associated with increased survival after open popliteal aneurysm repair compared to endovascular therapy.

Impact of Intraoperative Branch Embolization for Type 2 Endoleak Prevention During Endovascular Abdominal Aortic Repair

Endovascular abdominal aortic repair (EVAR) has a significantly higher revision rate than open repair, primarily due to Type 2 Endoleak (2EL). Although 2ELs are considered benign, late open conversion (LOC) due to the expansion of the aneurysm diameter of the 2EL is a concern in the mid- and long-term. In this study, we investigated the impact of embolization of the inferior mesenteric artery (IMA) or lumbar artery (LA) at the time of the initial EVAR and its long-term outcomes. Between April 2008 and December 2021, 743 EVAR procedures for abdominal aortic aneurysms (AAAs) were performed at our institution. The patients were divided into two groups at the time of initial surgery, namely, 215 and 528 patients in the embolization (Group E) and non-embolization (Group N) groups, respectively. Branch embolization was performed in patients with an IMA diameter ≥3 mm and LA diameter ≥2 mm on preoperative computed tomography. Re-embolization with EL was performed in patients with a diameter enlargement ≥10 mm, and LOC was performed in patients with continued enlargement ≥15 mm after re-embolization. The mean follow-up period was 7.0 years. The mean number of branch embolizations was 2.3±1.1. Intraoperatively, the operative time, fluoroscopy time, irradiation dose, and contrast medium use were significantly higher in Group E than in Group N. There was a significant difference between the two groups regarding shrinkage (Groups E vs. N: 45.6% vs. 37.3%; p=0.03) and enlargement (Groups E vs. N: 9.3% vs. 19.5%; p<0.001) of the aneurysm diameter by >5 mm after EVAR. In the mid- and long-term, the avoidance rate of 2EL reintervention was significantly lower in Group E at 5 years (93.5% vs. 88.6%) and 10 years (87.5% vs. 76.4%; p=0.04). LOC prevention was 5 years; Group E: 100% vs. 96.9% for Group N, and 10 years; Group E: 98.8% vs. 92.5% for Group N, significantly lower in Group E (p=0.02). The impact of branch embolization at the time of the initial EVAR is believed to prevent enlargement of the aneurysmal sac and LOC. However, prolonged operation time, increased radiation exposure, and the use of contrast medium have been debated. To improve the long-term results of EVAR, embolisms of both the IMA and LA are required.

Moderate hypothermic circulatory arrest with antegrade cerebral perfusion for the open repair of juxtarenal abdominal aortic aneurysm repair with shaggy aorta

Shaggy aorta is severe luminal surface degeneration of the aorta leading to an increased risk of plaque destabilization and embolization to the peripheral or visceral vessel beds. It represents a challenging clinical entity for both endovascular and open repair owing to potential atheroembolization, increased early morbidity and mortality, and poor long-term survival. Patients may be denied repair owing to its high risks. Herein, we present a novel approach to open repair of a juxtarenal abdominal aortic aneurysm with shaggy aorta using moderate hypothermic circulatory arrest with antegrade cerebral perfusion and concurrent flow modification to mitigate the risk of atheroma embolism.

Development and Application of Integrated Injection System for Injection and Profile Control in Dagang Oilfield

Abstract Dagang Oilfield is a heterogeneous, multi-layered, and structurally complex fault block oil reservoir. During the production process, the contradictions between layers and within layers are becoming increasingly prominent. Split injection and profile control are two important development processes for ensuring production and increasing production in current oilfield development. However, during the construction process of split injection wells for profile control, there are often problems with plugging agents, which affect the effectiveness of split injection and the success rate of testing and adjustment, and even require well repair operations. This has become a key quality control production link that affects the efficiency of oil recovery construction and the improvement of quality, cost, and efficiency. The idea of developing a new type of integrated water distributor for injection and profile control has been proposed, which can achieve dual functions of layered water injection and profile control using a set of pipe columns. Through several years of technological breakthroughs, technological breakthroughs have been made in various aspects such as main structure design, anti backflow structure design, and water nozzle optimization design. Innovative proposals have been made and the integrated water distribution device structure design for injection and profile control has been successfully developed, fundamentally solving the pain points and difficulties of low measurement and adjustment rate after injection well profile control construction, significantly improving the qualification rate of measurement and adjustment, and significantly improving work efficiency and construction quality.

Comparative analysis of robotic and laparoscopic techniques in hiatal hernia and crural repair: a review of current evidence and outcomes.

The purpose of this narrative review is to evaluate the implementation of robotic surgery in hiatal hernia and crural repair, based on the existing literature and to compare this approach to other established techniques. We performed a non- systematic literature search of PubMed and MEDLINE on February 25, 2024 for papers published to date focusing on the surgical repair of hiatal hernias using the robotic platform. After eliminating publications based on eligibility criteria, 13 studies were selected for analysis. Robotic surgery is increasingly utilized in hiatal hernia repair due to its enhanced ergonomics and superior visualization capabilities. Operative times vary, with some studies indicating longer durations for robotic surgery (e.g., Giovannetti et al. demonstrated median operative time of 196min for robotic compared to 145min for laparoscopic) while others report shorter times (e.g., Lang F et al. demonstrated 88min for robotic versus 102min for laparoscopic). Recurrence rates between robotic and laparoscopic repairs are comparable, with reported recurrence rates of 1.8% for robotic and 1.2% for laparoscopic approaches by Benedix et al. Robotic surgery offers potential advantages, including reduced intraoperative blood loss (e.g., Giovannetti et al. mentioned median blood loss of 20ml for robotic versus 50ml for laparoscopic). The length of hospital stay and postoperative complication rates also vary, with some studies suggesting shorter stays and fewer complications for robotic surgery as surgeons become more proficient. Soliman et al. reported a statistically significant reduction in complication rates with robotic surgery (6.3% versus 19.2%). Robotic surgery presents promising results regarding the length of hospital stay, conversion rate to open surgery and postoperative complication rates when compared to laparoscopy based on the existing literature. Despite the lack of striking differences, robotic hiatal hernia repair is a valid and evolving approach.