Running Suture Research Articles

Neonatal repair of total anomalous pulmonary venous connection accompanied by unilateral lung agenesis and Goldenhar syndrome: a case report

BackgroundTotal anomalous pulmonary venous connection accompanied by unilateral lung agenesis and Goldenhar syndrome is extremely rare.Case presentationWe present a case of total anomalous pulmonary venous connection accompanied by unilateral lung agenesis and Goldenhar syndrome in a patient who was diagnosed based on transthoracic echocardiography and computed tomography. We observed complete absence of the lung, the bronchial tree, and vascular structures on the right side, with abnormal drainage of the left pulmonary veins into the innominate vein. The patient showed clear clinical evidence of pulmonary venous obstruction and underwent surgery 3 days after birth. The pulmonary venous chamber containing the vertical vein was anastomosed to the left atrium using 7–0 PDS running sutures via a median sternotomy. Echocardiography and computed tomography performed 1 year postoperatively revealed no pulmonary venous obstruction.ConclusionWe report a rare case of total anomalous pulmonary venous connection accompanied by unilateral lung agenesis and Goldenhar syndrome, which was successfully repaired 3 days after birth. A median sternotomy is a safe and effective approach for surgical repair of congenital heart disease with unilateral lung agenesis. Repair of the supra cardiac total anomalous pulmonary connection using the vertical vein is feasible in patients with a small pulmonary venous chamber.

Virtual medical student dermatologic surgery workshop increases confidence in suturing and skin biopsy skills in the era of COVID-19

Background: During the COVID-19 pandemic, many pre-clinical medical school courses were conducted virtually. In order to increase exposure to basic procedures in the remote learning setting, our group developed a virtual dermatologic surgery workshop.
 Objective: To evaluate whether a virtual dermatologic surgery workshop increases medical student confidence in their ability to perform suturing and skin biopsies.
 Methods: All 147 second-year medical students at the University of Pittsburgh watched 70 minutes of pre-recorded lectures that introduced suturing, skin biopsies, and other dermatologic procedures. Each student was provided with a suturing kit to remotely practice the following skills: simple interrupted suture, simple running suture, horizontal mattress suture, vertical mattress suture, running subcuticular suture, shave biopsy, and punch biopsy. Pre- and post-workshop surveys were distributed to the students and paired using a randomized de-identified number.
 Results: 117 (80%) students completed the pre-survey and 71 (48%) completed the post-survey. 61 (41%) responses were paired. The average baseline level of confidence ranged from 1.0 on a 10-point scale for subcuticular running suture to 2.4 for simple interrupted suture. The average level of confidence increased after the workshop for each skill, ranging from 3.7 for subcuticular running suture to 8.0 for instrument tie. In the paired responses, the average level of confidence increased significantly for each skill by an average of 5.5 points (SD=1.1, p<.001).
 Conclusions: A virtual, asynchronous dermatologic surgery workshop significantly increases medical student confidence in their ability to perform suturing and skin biopsies.

Robotic endoscopic cooperative surgery for colorectal tumors: a feasibility study (with video).

Laparoscopic endoscopic cooperative colorectal surgery (LECS-CR) is a promising technique to achieve full-thickness resection of colorectal tumors. This approach has shown good rates of complete resection and low local recurrence, especially for large laterally spreading tumors, which are difficult to remove via endoscopy alone. However, it is often difficult to prevent peritoneal leakage of intestinal content, causing infections and risks of cancer spreading. It was hypothesized that a robotic assistance could make the procedure easier and decrease intestinal fluid leakage. This preclinical trial aims to assess the feasibility of robotic and endoscopic cooperative colorectal surgery (RECS-CR). LECS-CR was performed in five female pigs and RECS-CR was also performed in five female pigs. With the animal under general anesthesia, pseudotumors were created on the colonic mucosa at a distance comprised between 20 and 25cm from the anal verge. Desired resection margins were marked endoscopically and two stay sutures were placed either robotically or laparoscopically. A mucosa-to-submucosa dissection was performed endoscopically along the markings. Complete full-thickness dissection was performed cooperatively. The specimen was withdrawn endoscopically. The colon was closed using a self-fixating running suture. Abdominal contaminations, operating times, complications, and complete resections were evaluated and compared between LECS-CR and RECS-CR. The mean number of colonies of Escherichia coli in the RECS group was significantly lower than in the LECS group (36.7 ± 30.2 vs. 142.2 ± 78.4, respectively, p < 0.05). Operating time was comparable (118 ± 11.2 vs. 98.6 ± 25.7, respectively, p = 0.22). Two stenoses occurred in the LECS group. R0 resection was achieved in all cases. This study suggests that RECS-CR is feasible and has the potential to reduce intestinal content leakage, potentially preventing postoperative infections.

High rate of incisional hernia observed after mass closure of burst abdomen.

This study investigated the long-term development of incisional hernia after implementation of a standardized surgical treatment strategy for burst abdomen in abdominal midline incisions with a continuous mass closure technique. The study was a single-center, observational study evaluating all patients treated for burst abdomen between June 2014 and April 2019 with a long-term follow-up in October 2020. In June 2014, a standardized surgical treatment for burst abdomen involving a monofilament, slowly absorbable suture in a continuous mass-closure stitch with large bites of 3cm and small steps of 5mm was introduced. The occurrence of incisional hernia was investigated and defined as a radiological-, clinical-, or intraoperative finding of a hernia in the abdominal midline incision at follow-up. Ninety-four patients suffered from burst abdomen during the study period. Eighty patients were eligible for follow-up. The index surgery prior to burst abdomen was an emergency laparotomy in 78% (62/80) of the patients. Nineteen patients died within the first 30 postoperative days and 61 patients were available for further analysis. The long-term incisional hernia rate was 33% (20/61) with a median follow-up of 17months (min 4, max 67months). Standardized surgery for burst abdomen with a mass-closure technique using slow absorbable running suture results in high rates of long-term incisional hernias, comparable to the hernia rates reported in the literature among this group of patients.

Parachute technique for portal vein reconstruction during pancreaticoduodenectomy with portal vein resection in patients with pancreatic head cancer.

The most appropriate venous reconstruction method remains debatable when a long section of portal vein (PV) and/or superior mesenteric vein (SMV) must be resected in patients undergoing a pancreaticoduodenectomy (PD). The aim of the present study was to describe the technical details of the parachute technique, a modified end-to-end anastomotic maneuver that can be used in the above-mentioned circumstances, and to investigate its safety and feasibility. Patients who underwent venous reconstruction using the parachute technique after receiving a PD with PV resection for pancreatic cancer between January 2014 and March 2019 were retrospectively reviewed. For the parachute technique, the posterior wall was sutured in a continuous fashion while the stitches were left untightened. The stitches were then tightened from both sides after the running suture of the posterior wall had been completed, thereby dispersing the tension applied to the stitched venous wall when the venous ends were brought together and solving any problems that would otherwise have been caused by over-tension. The postoperative outcomes and PV patency were then investigated. Fifteen patients were identified. The median length of the resected PV/SMV measured in vivo was 5cm (range, 3-6cm). The splenic vein was resected in all the patients and was reconstructed in 13 patients (87%). The overall postoperative complication rate (≥ Clavien-Dindo grade I) was 60%, while a major complication (≥ Clavien-Dindo grade IIIa) occurred in 1 patient (7%). No postoperative deaths occurred in this series. The PV patency at 1year was 87%. The parachute technique is both safe and feasible and is a simple venous reconstruction procedure suitable for use in cases undergoing PD when the distance between the resected PV and SMV is relatively long.

Laparoscopic Sacrocervicopexy for Uterovaginal Prolapse: Step by Step for Safety and Efficiency

<h3>Study Objective</h3> The purpose of this video is to demonstrate the step by step of laparoscopic sacrocervicopexy for uterovaginal prolapse using a Y-shaped monofilament polypropylene mesh. <h3>Design</h3> Laparoscopic Subtotal hysterectomy is performed. After that, opening of the posterior peritoneum took place on the sacral promontory and was extended under the right uterosacral ligament. The Douglas pouch was then opened, and the rectovaginal plane was exposed. This maneuver was facilitated by the introduction and the relevant movements of a vaginal malleable valve. Dissecting the inter vesicovaginal space, the anterior mesh is on the anterior vaginal apex with two other sutures and the anterior mesh was fixed on the anterior vaginal wall just before the trigone and at the isthmus of the uterus. After that, the posterior mesh was fixed on the posterior vaginal apex with two other sutures and on the posterior vaginal wall. Both sutures with a 2/0 polygalactin suture. Mesh were anchored on the sacral promontory using a 0 polypropylene non absorbable suture on the longitudinal ligament. At the end, full peritonization of the mesh with a 2–0 polyglactin running suture. <h3>Setting</h3> Patient positioned in a Trendelenburg lithotomy position with legs slightly bent. A 10-mm trocar was placed at the umbilicus, two 5-mm trocars were positioned 2 cm above and medially to the anterior superior iliac spine and a third was positioned midway between the umbilicus and the pubic symphysis. <h3>Patients or Participants</h3> One 56 years old female patient with uterovaginal prolapse stage IV. <h3>Interventions</h3> laparoscopic sacrocervicopexy for uterovaginal prolapse with Y-shaped monofilament macroporous polypropylene mesh. <h3>Measurements and Main Results</h3> The laparoscopic sacrocervicopexy can be performed in patient at stage IV uterovaginal prolapse after partial hysterectomy in an efficient way. After the laparoscopic sacrocervicopexy surgery, the patient evolved with correction of the prolapse to stage I. <h3>Conclusion</h3> Laparoscopic surgery allows a good view of the vaginal walls performing this procedure safely and efficiently

LET'S MEET IN THE MIDDLE: SIMULTANEOUS ENDOSCOPIC AND BRONCHOSCOPIC SUTURE REPAIR TO CLOSE A LEFT MAIN-STEM MALIGNANT BRONCHO-ESOPHAGEAL FISTULA

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: This case highlights a unique approach to manage broncho-esophageal fistula which is refractory to esophageal stenting. CASE PRESENTATION: We describe the case of a 68 year old female with stage IV squamous cell carcinoma of the esophagus status post chemotherapy, immunotherapy and radiation complicated by esophageal stricture requiring a fully covered 18mmx12.3cm WallFlex stent. Approximately three months after stent placement, she developed coughing with oral intake. Swallow study revealed contrast refluxing into the trachea, and CT scan showed presence of left mainstem broncho-esophageal fistula. Bronchoscopy demonstrated thick purulent secretions and a 1-1.5 cm defect of the left main, 5mm distal to the main carina. The esophageal stent was visualized through the defect. She underwent EGD with removal of the stent and was also found to have a large 3cm deep defect in the proximal esophagus and ulceration throughout the mid-esophagus. Due to high risk of perforation, the esophagus was not stable enough to safely allow stent replacement. Her defect was deemed non-operable. Bronchial stenting was considered; however, there was increased risk of pressure necrosis and mediastinits plus proximity of the fistula to the main carina made stenting difficult to size. We opted to pursue simultaneous flexible endoscopy with rigid bronchoscopy to close her broncho-esophageal fistula. We utilized an X-Tack Endoscopic HeliX Tacking System with one running suture as well as placed two 2.0 36 inch braided non-absorbable pledgeted sutures from the esophageal side with closure on the bronchial side with a Cor-Knot device. There was no evidence of saline leak over the fistula. Post-closure, she tolerated bedside swallow and was able to drink liquid without coughing. Follow up esophagram is pending. DISCUSSION: The current standard of care for management of malignant tracheal-esophageal fistula is esophageal with/without broncho-tracheal stent and is palliative in intent. Stenting was not a safe option in our patient. The use sutures placed via rigid scopes from the esophageal side to tracheal side with closure with a Cor-Knot device for management of tracheo-esophageal fistula has been described in one prior case report.(1) Our case further demonstrates the feasibility of this technique for management of airway-esophageal fistula. Our case is unique as it treats a fistula in the left mainstem bronchus as opposed to the trachea. Due to the distal location of the defect, we were unable to use the rigid esophageal tube to pass the sutures, so we straightened the sutures and successfully passed them through a flexible EGD scope. Our case also used an X-Tack running suture device to further stabilize our closure. CONCLUSIONS: This case demonstrates an effective alternative approach and potentially more viable solution to treat broncho-esophageal fistulas when endoscopic/endobronchial stenting is not permissible. REFERENCE #1: Mozer AB, Michel E, Gillespie C, Bharat A. Bronchoendoscopic Repair of Tracheoesophageal Fistula. Am J Respir Crit Care Med. 2019 Sep 15;200(6):774-775. doi: 10.1164/rccm.201812-2255IM. PMID: 30973758; PMCID: PMC6775884. DISCLOSURES: No relevant relationships by Navtej Buttar, source=Web Response No relevant relationships by Sangita Goel, source=Web Response No relevant relationships by Ryan Kern, source=Web Response No relevant relationships by John Mullon, source=Web Response No relevant relationships by Darlene Nelson, source=Web Response Research grant relationship with Intuitive Surgical Please note: $5001 - $20000 by Janani Reisenauer, source=Web Response, value=Grant/Research Support No relevant relationships by Linh Vu, source=Web Response

Petersen hernia, a rare type of hernia in our department

61 years old female with previous surgical history of Roux-en-Y gastric bypass (3 years ago) and earlier hysterectomy admitted to our surgical department with clinical and radiological signs of small intestinal obstruction. Urgent intervention had been performed with following findings: Petersen herniation of alimentary tract including the – biliopancreatic tract and the small bowel extending to the midpart of the terminal ileum. Viability of herniated intestinal tract had been confirmed, and reposition of herniated parts through the Petersen hernia had been done. Closure with non-absorbable running suture of the gap between the transverse colon and the mesenteriun of the alimentary limb had been performed. Patient was fit for discharge on the fifth postoperative day.

Localization and Control of Magnetic Suture Needles in Cluttered Surgical Site with Blood and Tissue.

Real-time visual localization of needles is necessary for various surgical applications, including surgical automation and visual feedback. In this study we investigate localization and autonomous robotic control of needles in the context of our magneto-suturing system. Our system holds the potential for surgical manipulation with the benefit of minimal invasiveness and reduced patient side effects. However, the nonlinear magnetic fields produce unintuitive forces and demand delicate position-based control that exceeds the capabilities of direct human manipulation. This makes automatic needle localization a necessity. Our localization method combines neural network-based segmentation and classical techniques, and we are able to consistently locate our needle with 0.73 mm RMS error in clean environments and 2.72 mm RMS error in challenging environments with blood and occlusion. The average localization RMS error is 2.16 mm for all environments we used in the experiments. We combine this localization method with our closed-loop feedback control system to demonstrate the further applicability of localization to autonomous control. Our needle is able to follow a running suture path in (1) no blood, no tissue; (2) heavy blood, no tissue; (3) no blood, with tissue; and (4) heavy blood, with tissue environments. The tip position tracking error ranges from 2.6 mm to 3.7 mm RMS, opening the door towards autonomous suturing tasks.

V12-06 ROBOT ASSISTED RADICAL PROSTATECTOMY BY COMPLETE LATERAL ACCESS WITH PRESERVATION OF THE PUBOVESICAL COMPLEX: DESCRIPTION OF THE TECHNIQUE AND RESULTS

You have accessJournal of UrologyProstate Oncology I (Prostatectomy) (V12)1 Sep 2021V12-06 ROBOT ASSISTED RADICAL PROSTATECTOMY BY COMPLETE LATERAL ACCESS WITH PRESERVATION OF THE PUBOVESICAL COMPLEX: DESCRIPTION OF THE TECHNIQUE AND RESULTS Javier Reinoso Elbers, Moisés Rodríguez Socarras, Juan Gómez Rivas, Richard Gaston, Luis Llanes, Julio Fernández Del Álamo, Diego Carrion, and Fernando Gómez -Sancha Javier Reinoso ElbersJavier Reinoso Elbers More articles by this author , Moisés Rodríguez SocarrasMoisés Rodríguez Socarras More articles by this author , Juan Gómez RivasJuan Gómez Rivas More articles by this author , Richard GastonRichard Gaston More articles by this author , Luis LlanesLuis Llanes More articles by this author , Julio Fernández Del ÁlamoJulio Fernández Del Álamo More articles by this author , Diego CarrionDiego Carrion More articles by this author , and Fernando Gómez -SanchaFernando Gómez -Sancha More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002093.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Minimally invasive surgery for prostate cancer is constantly evolving. The development of technology and robotic surgery has contributed to a better understanding of prostate anatomy, allowing patients to receive an individualized treatment. The objective is to present the results of 302 consecutive patients treated of prostate cancer with robot assisted radical prostatectomy(RARP) by right lateral access with preservation of the pubovesical complex(PVC). METHODS: 302 specimens of patients undergoing robot assisted radical prostatectomy between January 2016 and May 2019 were studied. Demographic, preoperative, intraoperative, post-operative, oncologic and functional outcomes at 1½ year follow up were analyzed. Surgical technique: The principles of bladder neck preservation, tension and energy-free dissection of the bundles, seminal vesicle sparing, as well as PVC and Santorini´s plexus preservation are described. A lateral running suture is performed to restore continuity of the urinary tract. RESULTS: Mean surgical time was 139.34 min (SD+/-45.79). The complete lateral access and PVC preservation was feasible in 93.13% of cases. Mean hospital stay was 2,99 days (IQR+/-1.07). Complication rate was 6.53%(Clavien-Dindo I/II 3.59%).Clinically significant prostate cancer (ISUP ≥2) rate was 90.84%. Positive surgical margins (PSM) rate was 28%(93,2 %focal; 6.8% extensive). Biochemical recurrence at 1 1/2 year follow up was 0.092%. Total continence rate at 1,3,12 months was 75.24%,92.7% and 97.6%. Potency rate was 67.8% at 1 year follow up. CONCLUSIONS: The surgical treatment of prostate cancer with a lateral approach and complete pubovesical preservation is a safe and reproducible technique in well-selected cases. The results observed in this series are comparable to the robotic surgery series described in the literature by other working groups. Long-term follow-up of the series is necessary to define the oncological and functional results in this group of patients. Source of Funding: None. © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1025-e1025 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Javier Reinoso Elbers More articles by this author Moisés Rodríguez Socarras More articles by this author Juan Gómez Rivas More articles by this author Richard Gaston More articles by this author Luis Llanes More articles by this author Julio Fernández Del Álamo More articles by this author Diego Carrion More articles by this author Fernando Gómez -Sancha More articles by this author Expand All Advertisement Loading ...

Suturing of the Arachnoid Membrane for Reconstruction of the Cisterna Magna: Technical Considerations

Postoperative cerebrospinal fluid (CSF) fistula following cranial or spinal surgery is associated with increased morbidity and mortality. To prevent CSF fistulas, various techniques have been described. Here, we describe the arachnoid membrane continuous-running suture technique in cisterna magna reconstruction for preventing postoperative CSF leakage. After craniotomy and dural opening, the incision of the arachnoid of the cisterna magna was performed using a diamond blade. To prevent the arachnoid from drying out and shrinking during surgery, it was periodically irrigated with warm saline solution. Posterior fossa surgery was performed. When closing the membranes, the arachnoid membrane was closed with the running-suture technique. After the first surgical knot was made in the cranial end of the arachnoid opening, continuous suturing with a 2-mm distance between the stitches was performed without stretching them. After every 3 stitches, the free end of the thread was pulled gently along the suturing axis, and the edges of the arachnoid were closed. After the arachnoid edges were approximated, the surgical knot was tied. Watertight closure was checked byperforming the Valsalva maneuver at the end of the surgery. No CSF leakages were observed after surgery. Arachnoid membrane suturing seems to be safe and effective in preventing postoperative CSF leakage and CSF-related complications. Using continuous running suturing alone, without any sealant, might beeffective in cases with untraumatized arachnoid membrane.

Is the Dorsal Fiber-Splitting Approach to the Wrist Safe? A Kinematic Analysis and Introduction of the “Window” Approach

To compare the kinematic effects of the dorsal fiber-splitting approach for scapholunate ligament repair to a dorsal "window" approach that spares all ligaments. We randomized 24 fresh-frozen paired cadaveric forearms to either the dorsal fiber-splitting capsulotomy approach (FSC) or the dorsal window approach (window) following scapholunate interosseous ligament(SLIL) division. Loaded fluoroscopic radiographs were obtained after each of the 4 testing conditions following cyclic loading (200 cycles; 71 N): (1) intact SLIL, (2) SLIL-division, (3) surgical approach, and (4) closure. FSC specimens were randomly allocated to 2 subgroups for closure with either a suture anchor (n= 6) or a simple running suture closure (n= 6). Radiographic parameter measurements included the scapholunate gap, radiolunate angle, scapholunate angle, and dorsal scaphoid translation. Following the FSC, there were significant alterations in all radiographic parameters when compared with the intact and SLIL-division conditions. The window approach did not result in significant changes in any radiographic parameter. When compared to the window approach, all radiographic parameters of the FSC approach were significantly altered. Following closure with suture anchors in the FSC group, radiographic parameters improved, whereas with standard closure they failed to do so. Despite anchor closure, dorsal scaphoid translation, radiolunate angle, and scapholunate angle all remained elevated compared with scapholunate-divided wrists. The FSC produced significant changes in carpal posture under load, including scapholunate diastasis, dorsal intercalated segment instability, and dorsal scaphoid translation in SLIL-deficient wrists. The window approach preserved the critical dorsal ligament stabilizers and did not produce changes in carpal posture. The FSC may create iatrogenic changes in carpal posture that cannot be fully corrected with standard or anchor closure. The window approach does not alter carpal posture and should be considered when performing surgical procedures on the scaphoid or lunate.

Autologous semitendinosus tendon graft could function as a meniscal transplant

PurposeMeniscectomy results in poor knee function and increased risk for osteoarthritis. Meniscal allograft transplantation is not widely used due to costs and availability. The semitendinosus tendon (ST) has the potential to remodel and revascularize in an intraarticular environment, such as ACL reconstruction. The objective for this pilot study was to investigate whether the ST graft could function as a meniscal transplant.MethodsThe ST was doubled and sutured with running sutures and pull-out sutures in each end. Bone tunnels were used for root anchorage and the graft was sutured with allinside, inside-out and outside-in technique. The pull-out sutures were fixed over a button. Partial weight bearing was allowed with limited range of motion in a brace for the first 6 weeks. Evaluation was assessed using clinical examination, radiology and patient reported outcome.ResultsA total of seven patients have been included between January 2018 and June 2020. Six medial transplants and one lateral transplant were performed. Mean age was 29 years. Four patients had completed the 12-month follow-up. Improvements were noted for IKDC Global Score, KOOS pain subscale and Lysholm. MRI indicated that the transplant become more wedge-like with visible roots and minor protrusion.ConclusionsEven though this is primarily a technical report the follow-up data indicate that the transplant survives and adapts in shape and capabilities to an original meniscus. There were no adverse events and the patients seem to improve in terms of pain and quality of life.

Surgical technique of uretero-ileal anastomosis in patients with bilateral duplex ureters undergoing radical cystectomy and ileal conduit urinary diversion: initial experience

Background We present a simple technique for construction of wide ureteral plate, consisting of four ureters, incorporated in ureteroileal anastomosis of ileal conduit urinary diversion. Methods We retrospectively reviewed the charts of six cases of ureteral duplication (five bilateral and one unilateral) and muscle-invasive bladder cancer, treated with radical cystectomy and ileal conduit diversion, at our institution from 2015 to 2020. Briefly, our technique includes construction of wide ureteral plate, consisting of four ureters from two separate ureteral units, after previous construction of right and left ureteral plates for each unit, according to the standard Wallace technique. Additionally, during construction of definite ureteral anastomotic plate, we used a modified Wallace I technique consisted of eversion of posteromedial ureteral walls of both ureteral units, with muco-mucosal running suture. Results Four males and two females underwent radical cystectomy with ileal conduit for muscle invasive bladder cancer. A total of 12 complications (CDC I–III) were registered in 4/6 (66.6%) patients, whereby ten of them (83.3%) occurred within 90 days post-surgery. High-grade (CDC III) complications were registered in 33.3% of patients. Within the first three months post-surgery, hydronephrosis and high-grade vesicoureteral reflux were associated with pyelonephritis and observed in two patients (33.3%), while uretero-intestinal anastomotic stricture or leakage were not detected during follow-up in any patients. Conclusion Modified Wallace uretero-ileal anastomosis after radical cystectomy and ileal conduit urinary diversion is functionally and cosmetically effective way to treat patients with bilateral duplex ureters harbouring muscle invasive bladder cancer.

Indication and surgical techniques of bypass choledochojejunostomy for intractable choledocholithiasis.

Despite development in endoscopic treatment and minimally invasive surgery for choledocholithiasis, there remains a small number of patients who require bypass Roux-en-Y choledochojejunostomy (RYCJ) because of the intractable occurrence of common bile duct (CBD) stones. We herein present the detailed procedures of open RYCJ customized for intractable choledocholithiasis. The first method is a side-to-end choledochojejunostomy with intraluminal closure of the distal CBD. This method was applied to a 79-year-old female patient who underwent endoscopic retrograde cholangiopancreatography (ERCP) more than 10 times in the past 14 years (Case No. 1). The distal CBD was explored through choledochotomy and then the distal CBD lumen was occluded with internal running sutures. A large-sized choledochojejunostomy was performed. The patient recovered uneventfully and has been doing well for the past 2 years. The second method is an end-to-end choledochojejunostomy with segmental CBD resection. It was applied to a 75-year-old male patient who underwent ERCP 9 times in the past 10 years (Case No. 2). The CBD was resected segmentally and a large-sized choledochojejunostomy was performed. The patient also recovered uneventfully and has been doing well for the past 2 years. In conclusion, the primary indication of bypass RYCJ is intractable choledocholithiasis which requires numerous sessions of endoscopic stone removal over a long period. Open RYCJ is the preferred procedure to date. If the papilla is patulous, the distal CBD should be occluded or resected to prevent reflux ascending cholangitis. We recommend to resect the intrapancreatic distal CBD if it is markedly dilated like choledochal cyst.

Clinical application of "Double R" anastomosis technique in laparoscopic pancreaticoduodenectomy procedure.

Laparoscopic pancreaticoduodenectomy (LPD) is widely used as a treatment for periampullary tumors and pancreatic head tumors. However, postoperative pancreatic fistula (POPF), which significantly affects mortality and length of hospital stay of patients, remains one of the most common and serious complications following LPD. Though numerous technical modifications for pancreaticojejunostomy (PJ) have been proposed, POPF is still the “Achilles heel” of LPD.To reduce POPF rate and other postoperative complications following LPD by exploring the best approach to manage with the pancreatic remnant, a novel duct-to-mucosa anastomosis technique named Double Layer Running Suture (Double R) for the PJ was established. During 2018 and 2020, a totally 35 patients who underwent LPD with Double R were included, data on the total operative time, PJ duration, estimated blood loss, recovery of bowel function, postoperative complications, and length of hospital stay were collected and analyzed.The average duration of surgery was (380 ± 69) minutes. The mean time for performing PJ was (34 ± 5) minutes. The average estimated blood loss was (180 ± 155) mL. The overall POPF rate was 8.6% (3/35), including 8.6% (3/35) for the biochemical leak, 0% (0/35) for Grade B, and 0% (0/35) for Grade C. No patient suffered from biliary fistula, post-pancreatectomy hemorrhage, and intra-abdominal infection, the 30-day mortality was 0%.Double R anastomosis is potentially a safe, reliable, and rapid anastomosis with a low rate of POPF and post-pancreatectomy hemorrhage. It provides surgeons more options when performing LPD. However, its safety and effectiveness should be verified further by a larger prospective multicenter study.

Prophylactic sublay non-absorbable mesh positioning following midline laparotomy in a clean-contaminated field: randomized clinical trial (PROMETHEUS)

Incisional hernia is a frequent postoperative complication after midline laparotomy. Prophylactic mesh augmentation in abdominal wall closure after elective surgery is recommended, but its role in emergency surgery is less well defined. This prospective randomized trial evaluated the incidence of incisional hernia in patients undergoing urgent midline laparotomy for clean-contaminated surgery. Closure using a slowly absorbable running suture was compared with closure using an additional sublay mesh (Parietex ProGrip™). Patients were randomized just before abdominal wall closure using computer-generated permuted blocks. Patients, care providers, staff collecting data, and those assessing the endpoints were all blinded to the group allocation. Patients were followed up for 24 months by means of clinical and ultrasonographic evaluations. From January 2015 to June 2018, 200 patients were randomized: 100 to primary closure (control group) and 100 to Parietex ProGrip™ mesh-supported closure (mesh group). Eight patients in the control group and six in the mesh group were lost to follow-up. By 24 months after surgery, 21 patients in the control group and six in the mesh group had developed incisional hernia (P = 0.002). There was no difference between groups in the incidence of haematoma (2 versus 5; P = 0.248) and superficial wound infection (4 versus 5; P = 0.733). Multivariable analysis confirmed the role of mesh in preventing incisional hernia (odds ratio 0.11, 95 per cent c.i. 0.03 to 0.37; P < 0.001). One patient in the mesh group required mesh removal because of deep infection. Prophylactic mesh-augmented abdominal wall closure after urgent laparotomy in clean-contaminated wounds is safe and effective in reducing the incidence of incisional hernia. Registration number: NCT04436887 (http://www.clinicaltrials.gov).

Endoscopic carpal tunnel release with or without suture: Does it make a difference? A case-control study

A case-control study was conducted to compare wound healing with or without skin suture after endoscopic carpal tunnel release. The primary endpoint was esthetics on the Manchester Scar Scale (MSS). Patients were recruited between April 2016 and April 2017. Inclusion criteria comprised carpal tunnel syndrome with clinical and electromyographic confirmation on the Canterbury NCS (nerve conduction studies) Severity Scale. Age, gender, occupation, handedness, smoking status, and operated side were noted. In the first group (64 patients) the skin was not sutured. In the second group (44 patients) the skin was closed Ethilon™ 5-0 intradermal running suture. All 108 patients had 3 months’ follow-up. Since data were not normally distributed, analysis was performed with the Mann–Whitney U test (MWU) for independent samples. There were no significant differences in age (p = 0,416), gender (p = 0.670) or occupation (p = 0.725) between groups. MSS score did not significantly differ between groups (MWU test; p = 0.529): sutureless, 6.64 ± 1.21; sutured, 6.45 + 1.09. Thus, sutureless wound closure can be a useful option in treating carpal tunnel syndrome by a single-portal endoscopic technique. That the wound remains open enables easy evacuation of any hematoma, avoiding pain due increased intra-tissular pressure.

Endoscopic sleeve gastroplasty: the "cable" technique.

Video 1Video demonstration of endoscopic sleeve gastroplasty performed using a novel suture pattern termed the "cable" technique.

Aggressive Resection of Malignant Paraaortic and Pelvic Tumors Accompanied by Arterial Reconstruction with Synthetic Arterial Graft

Case seriesPatients: Female, 53-year-old • Female, 70-year-old • Female, 53-year-old • Female, 48-year-old • Male, 66-year-old • Female, 43-year-old • Male, 76-year-oldFinal Diagnosis: Local recurrenceSymptoms: AsymptomaticMedication: —Clinical Procedure: Surgical resectionSpecialty: SurgeryObjective:Unusual setting of medical careBackground:Advanced malignancies in the lower abdomen easily invade the retroperitoneal and pelvic space and often metastasize to the paraaortic and pelvic lymph nodes (LNs), resulting in paraaortic and/or pelvic tumor (PPT).Case Reports:A total of 7 cases of aggressive malignant PPT resection and orthotopic replacement of the abdominal aorta and/or iliac arteries with synthetic arterial graft (SAG) were experienced during 16 years. We present our experience with aggressive resection of malignant PPTs accompanied by arterial reconstruction with SAG in detail. The primary diseases included 2 cases endometrial cancer and 2 cases of rectal cancer, and 1 case each of ovarian carcinosarcoma, vaginal malignant melanoma, and sigmoid cancer. Surgical procedures are described in detail. Briefly, the abdominal aorta and iliac arteries were anastomosed to the SAG by continuous running suture using unabsorbent polypropylene. Five Y-shaped and 2 I-shaped SAGs were used. This en bloc resection actually provided safe surgical margins, and tumor exposures were not pathologically observed in the cut surfaces. Graphical and surgical curability were obtained in all cases in which aggressive malignant PPT resections were performed. The short-term postoperative course of our patients was uneventful. From a vascular perspective, the SAGs remained patent over the long term after surgery, and long-term oncologic outcomes were satisfactory.Conclusions:To our knowledge, this case series is the first report of aggressive malignant PPT resection accompanied by arterial reconstruction with SAG. This procedure is safe and feasible, shows curative potential, and may play a role in multidisciplinary management of malignant PPTs.