Significant Reduction In Operative Time Research Articles

Bypassing large submucosal vessels during peroral endoscopic myotomy reduces operative time and intraoperative blood loss in patients with achalasia.

peroral endoscopic myotomy (POEM), a relatively minimally invasive endoscopic procedure, is the first-line treatment for achalasia. The aim of this study was to compare procedure-related parameters and clinical outcomes between bypassing and performing prophylactic electrocoagulation of large submucosal vessels during POEM. one hundred and twelve patients with achalasia who had undergone POEM at our hospital between April 2017 and March 2023 were retrospectively enrolled. Large submucosal vessels were bypassed to avoid injury during submucosal tunneling in the bypass group, whereas large submucosal vessels were prophylactically treated by electrocoagulation in the prophylactic electrocoagulation group. Procedure-related parameters, Eckardt score and complications were compared between the two groups. the bypass group showed a significant reduction in operative time and amount of intraoperative blood loss than the prophylactic electrocoagulation group (37.11 ± 9.96 min vs 58.80 ± 17.90 min, and 1 [interquartile range: 1-2] ml vs 5 [interquartile range: 3-8] ml; p < 0.001). Eleven (17.5 %) and 44 (89.8 %) patients in the bypass and prophylactic electrocoagulation groups, respectively, required hemostatic forceps (p < 0.001). Furthermore, lower operative and hospitalization costs were recorded in the bypass group than in the prophylactic electrocoagulation group (p < 0.05). No statistically significant difference was found between the two groups in terms of submucosal tunnel length, myotomy length, clinical efficacy, or complications. bypassing large submucosal vessels during POEM can reduce the operative duration and intraoperative blood loss, with no difference in clinical outcomes than prophylactic electrocoagulation treatment.

Modified chest wall lateral intercostal artery perforator (MCW‐LICAP) flap: a versatile flap in the era of oncoplastic breast surgery

Breast reconstruction following oncological resection is becoming more common in recent years. In some ladies, implant reconstruction is not ideal due to significant implant visibility or palpability. Autologous reconstruction addresses the limitations of implant reconstruction but results in potential donor site morbidities. To date, there is no clear advantage ascribed to any technique. With appropriate selection, patients with adequate lateral mammary fold have the option of reconstruction with MCW-LICAP flap. We present our techniques and outcomes from a series of 29 patients who underwent MCW-LICAP flap. A retrospective review of consecutive patients who underwent curative resection for breast cancer with immediate MCW-LICAP flap reconstruction, between July 2018 to April 2022 was conducted. The techniques used with its variations along with video demonstrations are presented. A total of 29 patients underwent 34 procedures. Nineteen breast conserving surgeries and 15 mastectomies were completed, and immediate reconstruction performed in all cases. Twenty-three patients had MCW-LICAP, 1 with a Stacked intercostal artery perforator (STICAP) flap, and 5 had MCW-LICAP combined with a Goldilocks mastectomy. There were no cases of complications requiring re-operation. All patients had acceptable time to adjuvant therapy with a median of 36 days. Learning curve analysis showed a significant reduction in operative time after the 6th case. In our preliminary experience, MCW-LICAP flap is a safe, reliable, and versatile oncoplastic reconstruction option.

Postoperative results of the in situ fenestrated open stent technique for acute aortic dissection type A

ObjectiveTotal arch replacement is commonly used for acute aortic dissection type A at some facilities, especially since open stent grafting became commercially available in Japan. Left subclavian artery (LSCA) reconstruction involves deep view manipulation, is difficult to expose and anastomose, and involves the risk of complications and surrounding vascular injury.MethodsWe evaluated 137 patients (mean age 73.8 ± 15.6 years) who underwent total arch replacement for acute aortic dissection type A, at our hospital between September 2014 and March 2022, and divided them into two groups: 70 patients for total arch replacement with fenestrated open stent technique (FeneOS), and 67 for conventional total arch replacement with the reconstruction of three-branch cerebral vessels. We performed FeneOS by deploying the graft from the entry of the left subclavian artery into the descending aorta and fenestrating the LSCA side of the stenting portion. The four-branched artificial vessel was then anastomosed between the left common carotid artery and LSCA.ResultsThe surgical results of FeneOS were satisfactory and enabled significant reductions in operative time, selective cerebral perfusion time, cardiopulmonary bypass time, and lower body circulatory arrest time. Long-term observation (mean follow-up = 5.5 years) showed no left recurrent laryngeal nerve palsy or postoperative problems with left subclavian artery blood flow.ConclusionsFeneOS can minimize LSCA exposure because there is no need for LSCA reconstruction, reducing operation time and avoiding the risk of left recurrent laryngeal nerve injury and bleeding problems associated with LSCA exposure and anastomosis during left subclavian artery exposure.

Efficacy of transperineal minimally invasive surgery with laparoscopic abdominoperineal excision for lower rectal cancer.

In abdominoperineal excision (APE), the advantages of the "down-to-up" approach are expected to be more obvious when performed as a two-team approach, including transperineal minimally invasive surgery (TpMIS). We investigated the efficacy of TpMIS with laparoscopic APE for lower rectal cancer. Patients who underwent laparoscopic APE with (n = 20) or without (n = 30) TpMIS between December 2013 and April 2020 were retrospectively reviewed. Patient and tumor characteristics, intraoperative outcome, short-term outcome, and pathological findings were compared. Additional subgroup analyses were performed in technically challenging cases, including male patients, obese patients, and patients with tumors located at the anterior wall. There was no marked difference in the patient or tumor characteristics or short-term outcomes, including morbidity and mortality between the two groups. Pathological results were comparable, and the circumferential resection margin (CRM) positive rate was 10% in both groups. TpMIS achieved a significant reduction in operative time (p = 0.02). In a subgroup analysis, the amount of blood loss was also smaller in males (p = 0.02) and patients with a high BMI (> 25) (p = 0.005) than in others. Simultaneously performing TpMIS and laparoscopic APE is feasible owing to the favorable complication and CRM-positive rates. In terms of operative time and blood loss, TpMIS is expected to be advantageous in both easy and challenging cases.

Virtual surgical planning for maxillary reconstruction with the scapular free flap: An evaluation of a simple cutting guide design.

The study's objective is to assess the feasibility and utility of VSP for maxillary reconstruction with the scapular free flap. An open-source VSP platform was used to create the reconstruction models and simple guides. Clinical, operative, and postoperative data were collected. Ten patients in the VSP cohort and 18 in the non-VSP control cohort were included in the study. There was a significant reduction in operative time (256.0 ± 69.4 vs. 448.1 ± 108.2min, p < 0.01), tracheotomy rate (20% vs. 72%, p < 0.01), increased two-team utilization rate (80% vs. 0%, p < 0.01) and better reconstructive accuracy (7.5 ± 3.4 vs. 11.7 ± 7.6 mm, p=0.048) for the VSP cohort. Maxillary reconstruction planned with an in-house open-source VSP platform and accompanied simple guides can facilitate a two-team approach, reduce operative time, and improve structural accuracy. This open-source technology has great potential to be readily applied in other institutions to improve efficiency and outcomes.

Robotic Heller-Dor procedure for oesophageal achalasia: Fluorescence-guided intraoperative assessment of myotomy. A retrospective single-centre experience.

The robotic Heller-Dor (RHD) procedure for oesophageal achalasia (EA) is safe and effective. We aim to evaluate the intraoperative use of fluorescence imaging, as an alternative means to intraoperative endoscopy, to assess myotomy at the end of the procedure. Thirty-four patients affected with EA underwent RHD. The myotomy was assessed intraoperatively by endoscopy in group A (17 patients), and by fluorescence imaging in group B (17 patients). Perioperative and long-term results were compared. In group A, one mucosal tear was identified during intraoperative endoscopy. In group B, indocyanine green (ICG) helped identify residual muscle fibres in three cases. No perforation of the oesophageal mucosa occurred in group B. Fluorescence-imaging improved the identification of residual muscle fibres and made it possible to verify the integrity of the mucosa without the use of intraoperative endoscopy. A significant reduction in operative times has been related to the use of this technique.

LigaSure versus Conventional Parotidectomy: A Systematic Review and Meta-Analysis

Surgery with parotidectomy is the preferable treatment for most parotid tumors. Our meta-analysis compared the differences between the use of the LigaSure (LS) device and the conventional suture ligation technique (CT) in parotidectomies. A literature search in databases including EMBASE, MEDLINE, and the Cochrane Library was carried out. Studies including parotidectomy using LS and CT were included with the intraoperative and postoperative parameters collected. Continuous operative time data were measured by mean differences (MDs). Discrete data on postoperative complications, including facial palsy, postoperative bleeding, and salivary complications, were evaluated with risk differences (RDs). All values were reported with 95% confidence intervals (CIs). Five studies were included in our meta-analysis. The pooled analysis demonstrated a significant reduction in operative time in the LS group (MD: −21.92; 95% CI, −30.18 to −13.66). In addition, the analysis indicated that the incidence of postoperative complications, including permanent facial palsy (RD, −0.01; 95% CI, −0.06 to 0.05), temporary facial palsy (RD, 0.00; 95% CI, −0.03 to 0.04), salivary complications (RD, −0.01; 95% CI, −0.08 to 0.06), and postoperative bleeding (RD, −0.02; 95% CI, −0.07 to 0.04), were all similar between the LS group and the CT group. According to the results, the LS device appears to be a safe and useful tool and could shorten the operative time in patients needing parotidectomy.

Endoscopic versus open surgical approaches for colloid cyst of the third ventricle

Colloid cysts are benign lesions of the anterior part of the third ventricle. Surgery is the main line of treatment. Endoscopic treatment gained wide acceptance among neurosurgeons. However, open microsurgical approaches still recommended by many surgeons. Each approach had its own advantages and drawbacks. The current study designed to explore the outcome of endoscopic versus open colloid cystectomy for the colloid cyst of the third ventricle. This is a retrospective study of patients who submitted to third ventricle colloid cystectomy during a duration of 10 years. A total number of 41 patients were included (20 managed by endoscopic approach and 21 by open surgery). Files were reviewed for preoperative (clinical examination and radiological investigations), operative (e.g, operative time, the size of the cyst and additional interventions) and postoperative outcome. Both approaches were comparable regarding demographics, preoperative, operative and postoperative data, except significant reduction of operative time and total duration of hospital stay among endoscopy than open group (127.95±18.32, 5.30±1.69 vs 178.33±20.51 and 8.95±1.62 respectively). The recurrence was reported among 3 patients (7.3%) (2 in the endoscopy and 1 in the open group). Among 90.0% of endoscopy group, their neurological condition was improved compared to 95.2% of open group.

Use of energy device in general surgical operations: impact on peri-operative outcomes

BackgroundThe introduction of energy devices has significantly expanded the scope of surgical expedition. The LigaSure™ vessel sealing system is a bipolar electrosurgical device, recently introduced to our practice. Its impact on peri-operative outcomes in a variety of major operations was evaluated in this study.MethodsA retrospective review of operations performed following the adoption of the LigaSure™ vessel sealing device was carried out. Five categories of operations were evaluated (Thyroidectomies, Gastrectomies, Colectomies, Pancreaticoduodenectomies, and Anterior/Abdomino-perineal resection [A/APR of the rectum). Peri-operative outcomes (duration of operation, intra-operative blood loss, blood transfusion rates) were compared with a cohort of similar operations performed using conventional techniques. Data analysis and comparisons were done on a subgroup basis.ResultsA total of 117 operations were performed using the LigaSure™ device with thyroidectomies being the most common (66/117-56.4%). Compared to cases done using conventional techniques of suture and knot with electrocautery (120 cases), the use of LigaSure™ was associated with a significant reduction in operation time in all categories of operations. Intraoperative blood loss was also lower in all categories of cases, but this was only statistically significant following A/APR and Thyroidectomies. Generally, there was a trend towards a reduction in blood transfusion rates.ConclusionsThe use of energy devices for surgical operations is feasible in a resource-limited setting. It has the potential of improving outcomes.

Comparison of Operative Time and Blood Loss With the FFX® Device Versus Pedicle Screw Fixation During Surgery for Lumbar Spinal Stenosis: A Retrospective Cohort Study.

BackgroundPedicle screw (PS) placement can be associated with soft tissue damage and blood loss. The study objective was to evaluate differences in operative time and blood loss between PS fixation and an implantable facet fusion device in patients undergoing lumbar fusion surgery.Materials and methodsA retrospective analysis was performed on patients undergoing lumbar fusion surgery with PS fixation or the lumbar Facet FiXation (FFX) device. Procedures were performed by the same surgeon at a single institution. The PS group included patients from 2016 and the FFX group included patients from 2018. Variables including age, sex, levels operated on, operative time, and operative blood loss were collected.ResultsA total of 70 patients were included in the study. Twenty-eight in the PS arm and 42 in the FFX arm. The PS group had a mean age of 67.5 ± 9.3 years compared to 70.4 ± 11.5 years for the FFX group. The PS group had a higher percentage of females (57.1%) versus the FFX group (31.0%); p = 0.025. Mean number of levels operated on were similar between the PS and FFX groups (2.3 ± 1 .1 vs. 2.2 ± 1.0, respectively; p = 0.89). Mean operative time was significantly longer for the PS group versus the FFX group (152.5 ± 39.4 vs. 99.4 ± 44.0 minutes; p < 0.001). Mean operative blood loss was significantly greater for the PS group versus the FFX group (446.5 ± 272.0 vs. 251.0 ± 315.9 mL; p < 0.01). Differences were independent of the number of levels operated on.ConclusionPlacement of the FFX device is associated with a significant reduction in operative time and blood loss compared to PS fixation in patients undergoing spinal fusion surgery.

Must Clinics Replace 2D by 3D Environments for an Efficient Training of Laparoscopic Novices? A Critical Analysis of the Learning Curve for Basic Skills.

Background and AimsPublished studies repeatedly demonstrate an advantage of three-dimensional (3D) laparoscopic surgery over two-dimensional (2D) systems but with quite heterogeneous results. This raises the question whether clinics must replace 2D technologies to ensure effective training of future surgeons.MethodsWe recruited 45 students with no experience in laparoscopic surgery and comparable characteristics in terms of vision and frequency of video game usage. The students were randomly allocated to 3D (n = 23) or 2D (n = 22) groups and performed 10 runs of a laparoscopic “peg transfer” task in the Luebeck Toolbox. A repeated-measures ANOVA for operation times and a generalized linear mixed model for error rates were calculated. The main effects of laparoscopic condition and run, as well as the interaction term between the two, were examined.ResultsNo statistically significant differences in operation times and error rates were observed between 2D and 3D groups (p = 0.10 and p = 0.72, respectively). The learning curve showed a significant reduction in operation time and error rates (both p's < 0.001). No significant interactions between group and run were detected (operation time: p = 0.342, error rates: p = 0.83). With respect to both endpoints studied, the learning curves reached their plateau at the 7th run.ConclusionThe result of our study with laparoscopic novices revealed no significant difference between 2D and 3D technology with respect to performance time and the error rate in a simple standardized test. In the future, surgeons may thus still be trained in both techniques.

Intraoperative halo-femoral traction during posterior spinal arthrodesis for adolescent idiopathic scoliosis curves between 70° and 100°: a randomized controlled trial.

Surgical management of scoliosis curves between 70° and 100° remains controversial. The authors designed this randomized controlled trial to validate the efficacy of intraoperative halo-femoral traction (IOHFT) in patients with adolescent idiopathic scoliosis (AIS), Cobb angles between 70° and 100°, and flexibility < 35%. The authors prospectively recruited and randomized 29 patients with severe AIS scheduled for posterior surgery into a traction group or control (nontraction) group. The primary outcome measures were operative time, blood loss, and length of hospital stay. Secondary outcomes included degree of spine deformity correction, traction-related complications, and health-related quality of life. In the traction group, the average preoperative Cobb angle was 83.2°, with an average 20.6% flexibility. The average postoperative Cobb angle was 16.1° and the major curve was 18.3° at the final follow-up. In the control group, the average preoperative major curve was 80.3° with 22.8% flexibility. The average postoperative Cobb angle was 16.1° and the major curve was 18.1° at the final follow-up. The operative duration was 325.7 minutes for the traction group and 385.4 minutes for the control group (p = 0.018). Compared with the control group, the traction group had a 29.5% reduction in intraoperative blood loss and a significantly lower rate of blood transfusion (13.3% vs 50.0%, p = 0.033). There were no neurological complications in either group. One patient in the traction group had a superficial infection at the traction site. Use of IOHFT contributed to significant reductions in operative time and blood transfusion requirements, with no added morbidity. It is an effective and safe method to assist correction of AIS curves between 70° and 100° and flexibility < 35%.

Introduction of gasless laparoscopic surgery as a minimally invasive procedure for endometrial cancer and its usefulness from the viewpoint of the learning curve

BackgroundWe investigated the usefulness of gasless laparoscopic surgery (GLS) using a subcutaneous abdominal wall lifting method for endometrial cancer.MethodsWe studied 105 patients with early endometrial cancer who underwent GLS (55) or open surgery (50). A uterine manipulator was used in all GLS cases. We compared operative time, blood loss, number of lymph nodes removed, hospital stay, perioperative complications, cases converted to laparotomy, and recurrence and survival rates. We also studied the learning curve and proficiency of GLS.ResultsThe GLS group had significantly longer operative time (265 vs. 191 min), reduced blood loss (184 vs. 425 mL), shorter hospital stay (9.9 vs. 17.6 days), and fewer postoperative complications (1.8 vs. 12.0%) than the open group. No case was converted to laparotomy. Disease-free and overall survival rates at 4 years postoperatively (GLS vs. open groups) were 98.0 versus 97.8 and 100 versus 95.7%, respectively, and there was no significant difference between the groups. Regarding the learning curve for GLS, two different phases were observed in approximately 10 cases. Operator 2, who was not accustomed to laparoscopic surgery, showed a significant reduction in operative time in the later phase 2.ConclusionsGLS for endometrial cancer results in less bleeding, shorter hospital stay, and fewer complications than open surgery. Recurrence and survival rates were not significantly different from those of open surgery. This technique may be introduced in a short time for operators who are skilled at open surgery but not used to laparoscopic surgery.

Comparative study to evaluate ultrasonic verses monopolar electrocautery dissection of gall bladder in laparoscopic cholecystectomy

Background: Gallstones are one of the most common routinely encountered surgical problem in the developed world. Laparoscopic cholecystectomy being the gold standard surgery for gall stones has been modified various times using different instruments in order to improve intraoperative and postoperative outcomes. The aim of the study was to see clinical outcomes of ultrasonic scalpel verses monopolar electrocautery in dissection of gall bladder in laparoscopic cholecystectomy.Methods: A prospective randomized controlled study was done with total 100 patients in which 50 patients underwent laparoscopic cholecystectomy via ultrasonic scalpel while rest 50 patients were operated using monopolar electrocautery. The study was conducted for a period of eighteen months and clinical outcomes were studied in terms of operative time, frequency of lens cleaning, gall bladder perforation, biliary leak, common bile duct injury, bowel perforation and postoperative hospital stay.Results: The two groups were comparable in terms of demographic profile considering age and sex distribution. However, there was a statistically significant reduction in operative time, frequency of lens cleaning and gall bladder perforation in group A (harmonic scalpel) as compared to group B (electrocautery).Conclusions: Harmonic scalpel is not only a safe and effective instrument but also a reliable alternative to electrocautery. Even though the study revealed no significant difference in biliary leak, common bile duct injury, bowel perforation and postoperative hospital stay but it can significantly reduce operative time and incidence of gall bladder perforation. Thus, it can improve the operative course in laparoscopic cholecystectomy.

Comparing Plastic Surgeon Operative Time for DIEP Flap Breast Reconstruction: 2-stage More Efficient than 1-stage?

Background:The deep inferior epigastric perforator flap for breast reconstruction is associated with lengthy operative times that remain an issue for plastic surgeons today. The main objective of this study was to determine if a 2-stage deep inferior epigastric perforator flap reconstruction resulted in a shorter total plastic surgeon operative time compared with an immediate reconstruction.Methods:A retrospective chart review was conducted on all patients who underwent deep inferior epigastric perforator flap breast reconstruction from February 2013 to July 2020 by the senior author. Patient demographics, medical comorbidities, mastectomy characteristics, expander placement, reconstructive procedures, operative time, and complications were tabulated.Results:The study included a total of 128 patients. For immediate/1-stage flap reconstruction, average operative times for the plastic surgeon were 427.0 minutes for unilateral procedures, and 506.3 minutes for bilateral procedures. For delayed/2-stage reconstruction, average combined plastic surgeon operative times were 351.1 minutes for unilateral expander followed by flap reconstruction (75.9 minutes shorter than immediate unilateral, P = 0.007), and 464.8 minutes for bilateral reconstruction (41.5 minutes shorter than immediate bilateral, P = 0.04). Total patient time under anesthesia was longer for 2-staged bilateral reconstruction (P = 0.0001), but did not differ significantly for unilateral reconstruction. Complications between immediate and delayed groups were not significantly different.Conclusions:We found that staged reconstruction over 2 procedures resulted in a significant reduction in operative time for the plastic surgeon for both unilateral and bilateral reconstruction. With amenable breast surgeons and patients, the advantages of controlling scheduling and the operating room may encourage plastic surgeons to consider performing free flap reconstruction in a delayed fashion.

Clinical and patient-reported outcomes after robot-assisted short-segment lumbar fusion with a minimum 1-year follow-up

ObjectiveTo examine the complications and patient-reported outcomes after robot-assisted short-segment lumbar fusion surgery. MethodsWe reviewed a consecutive group of adult patients (≥18 years old) with lumbar degenerative disease who underwent a robot-assisted short lumbar fusion (1-, 2-level) between 2017 and 2019. The minimum follow-up was 1-year. Bivariate and multivariate analyses were performed to determine risk factors for the outcomes. ResultsA total of 51 patients underwent a robot-assisted short-segment (1-level: N = 33, 64.7%; 2-level: N = 18, 35.3%) lumbar fusion. The mean age ± standard deviation was 55.4 ± 12.9, and 52.9% of patients were female (N = 27). Intraoperative complications included dural tear (N = 3, 5.9%) and exchange of screws for breach (N = 3, 5.9%). No intraoperative motor/sensory loss was observed in this study sample. The mean length of stay was 2.8 ± 1.6 days. The 1-year readmission and reoperation rates were 11.8% (N = 6) and 7.8% (N = 4), respectively. The reasons for revision surgeries included wound complications requiring irrigation and debridement (N = 3) and disc herniation (N = 1, 2%). Overall, our patients experienced substantial improvements in ODI (MCID%: 6-weeks: 60.1%, 6-month: 78.8%, 1-year: 85.4%, and 2-year: 85.7%). For primary 1-level lumbar fusion, there was a significant reduction of 40 min after the first 20 cases (193 ± 30 min vs. 153 ± 55, p = 0.019). ConclusionsThe findings of our study on robot-assisted short-segment lumbar fusions demonstrate that comparable outcomes can be achieved with robotic assistance compared to those reported for both free-hand technique and other robotic systems in current literature. Most patients can expect to achieve substantial improvements in their PROs despite complications. Even after the first 20 cases, surgeons might experience a significant reduction in operative time using this robotic system.

Multidimensional Analyses of the Learning Curve of Endoscopic Thyroidectomy.

Endoscopic thyroidectomy has comparable surgical outcomes and superior cosmetic satisfaction to open thyroidectomy. However, steep learning curve is a concern. This study evaluated the learning curve of endoscopic thyroidectomy using various parameters and statistical methods. A total of 90 consecutive patients who underwent endoscopic thyroidectomy using bilateral axillo-breast approach (BABA) between March 2016 and April 2020 were enrolled. Operative time, postoperative drainage amount, and blood loss were assessed by cumulative sum (CUSUM) analysis and moving average to evaluate the learning curve. Using the CUSUM analysis, the peak point of both operative time and drainage amount occurred at the 30th case. No clear single peak was identified in the CUSUM plot for blood loss. The moving average also showed significant reduction in operative time and drainage amount after, approximately, the first 30 cases. The blood loss decreased after the 25th case. We therefore divided the patients into 2 phases: phase 1 (1-30 cases) and phase 2 (31-90 cases). The operative time, drainage amount, and blood loss decreased significantly in the phase 2 compared with phase 1. Lower pain score in first postoperative day and shorter hospital stay were also observed in the phase 2. Although the reduction in transient hypoparathyroidism did not reach statistical significance, no permanent hypoparathyroidism was noted in the phase 2. The learning curve for endoscopic thyroidectomy is approximately 30 cases. Aside from the operative time, drainage amount may also serve as a surrogate for the learning curve evaluation.

Single layer extramucosal versus double layer anastomosis for colostomy closure in children with anorectal malformation

Background: Intestinal anastomosis is one of the commonly performed procedure in gastrointestinal surgeries. The purpose of this study is to Assess safety, efficacy, cost effectiveness of single layer anastomosis over double layer anastomosis for colostomy closure in children with Anorectal Malformation at tertiary care centre. Materials and Methods: This prospective observational comparative study conducted between February 2016 to January 2021 consisting of 47 patients. All the children admitted for colostomy closure after definitive staged procedure for anorectal malformation were enrolled in the study. All anastomoses were of end-to-end type. The single layered anastomoses were performed by using interrupted 3-0 polydioxanone suture beginning at the mesenteric border and taking all layers of bowel wall except the mucosa into the bite. The double layered anastomoses were performed using interrupted 3-0 polydioxanone suture for the transmural inner layer and interrupted 3-0 polydioxanone Lembert sutures for outer seromuscular layer. Outcome parameters assessed were, quantity and cost of suture material used, time taken for anastomosis, time taken for surgery, postoperative return of peristalsis and passage of flatus, postoperative complications like paralytic ileus, bowel obstruction, anastomotic dehiscence diagnosed by presence of enteric contents like bile or faeces in drain or wound or diagnosed on radiological imaging like CT scans and hospital stay. Data were recorded in the case record form. Qualitative data was expressed in terms of proportions. Quantitative data was expressed in terms of Mean and Standard deviation. All the data collected was analysed by using SPSS 24.0 version IBM USA. Results: Out of total 47 children enrolled in study, 25 (53.19%)children were allocated to single layered extra mucosal intermittent anastomosis and 22 (46.81%) children to double layered anastomosis. All children admitted for colostomy closure had age ranges between 7 months to 36 months with mean age of 11.5 ±3.8 months.Amongst all the children undergoing anastomosis 35(74.47%) were males and 12(25.53%) were females. Observed outcome parameters like mean time taken for surgery in minutes (120.4±15.3 Vs 135.7±12.5), mean time taken for anastomosis in minutes (15.1±2.3 Vs 24.4±2.3), mean day of return of bowel sounds on postoperative day (2.40 Vs 3.74), mean day of first postoperative bowel movement (3.41 Vs 4.89 ) were significantly less in single layer anastomosis group than in double layer anastomosis. Suture material used in single layer anastomosis was lesser in quantity than used in double layer anastomosis. Post-operative complications were seen in 3 (06.38%) children of in single layer anastomosis group and 5 (10.63%) children of double layer anastomosis group. One child who underwent double layer anastomosis had anastomosis leak while none of child in single layer anastomosis group had leak. Mean duration of hospital stay was 5.95±1.40 days in single layer anastomosis group which is lesser than mean duration of hospital stay of 7.45 ± 1.95 days in double layer anastomosis group. Conclusion: Single layer intestinal anastomosis resulted in significant reduction in operative time, hastens the postoperative recovery of bowel function, reduces suture material, hospital stay and cost; without any difference in complications.

Endoscopic interlaminar lumbar discectomy: How to decrease the learning curve

Background: Herniated lumbar disc is a common cause of lumbosacral pain. Endoscopic interlaminar lumbar discectomy (ILD) is a well-established technique that provided comparable results to micro-discectomy. The aim of the study is to describe the learning curve of endoscopic ILD and explore measures that could improve effectiveness and decrease blood loss and operative time with accumulation of reasonable experience.Methods: This retrospective cohort study included 65 patients presenting with symptomatic herniated lumbar disc who underwent endoscopic ILD. Patients were divided into two groups: Group I (standard technique) and Group II (modified technique). Collected data included patients’ age, gender, preoperative manifestations, visual analog score (VAS) for pain, Oswestry Disability Index (ODI), disc level, operative time, intraoperative blood loss, complications, and follow-up data at 1, 6, and 12 months postoperatively. Primary outcomes included total operative time, amount of intraoperative blood loss, and post-operative improvement in pain. Secondary outcomes included intraoperative complications, rate of conversion to open surgery, and recurrence.Results: Post-operative VAS and ODI improved significantly in both groups. Mean total surgical time and intraoperative blood loss were significantly lower in Group II compared to Group I (P < 0.001). The learning curves for operative time and intraoperative blood loss were shallow in Group I, and almost flattened in Group II. Complications were recorded in only three cases, and no symptomatic recurrences were reported.Conclusion: The learning curve of endoscopic ILD was shallow with standard technique, indicating difficulties in mastering the procedure. The proposed modified technique helped reaching the required level of proficiency in the early phase of the curve, providing a significant reduction in operative time and blood loss, with comparable effectiveness and safety as the standard technique.

Clinical evaluation of an automated virtual surgical planning platform for mandibular reconstruction.

Virtual surgical planning (VSP), via commercial services or developed in-house, has been applied to facilitate head and neck reconstruction. We evaluate a custom, automated planning software. Prospectively, VSP of 25 consecutive patients undergoing segmental mandibular reconstruction was performed. Postoperative CT was used to assess structural accuracy of VSP. Operative time, length of stay, and complication rate of the prospective cohort were compared with those of 25 consecutive retrospective historical cases. The deviations between the plan and execution in mandibular width, projection, and volumetric overlap were 2.32 ± 3.91, 2.39 ± 1.72, and 0.59 ± 0.51 mm respectively. Compared with historical data, there was a significant reduction in operative time and length of stay, and no significant difference in complication rates. This is the largest prospective series evaluating an in-house VSP workflow for mandibular reconstruction and the first clinical evaluation of an automated planning platform.