Simple Closure Research Articles

Effectiveness of Subcutaneous Suction Drain vs. Simple Skin Closure in Reducing Postoperative Surgical Site Infections After Emergency Laparotomy

Background: Surgical Site Infections (SSIs) are prevalent complications following surgeries, especially after major abdominal procedures like emergency laparotomies. In resource-limited settings such as Bangladesh, effective strategies to reduce SSIs are crucial for improving patient outcomes. Objective: This study aims to evaluate the effectiveness of subcutaneous suction drains versus simple skin closure in reducing postoperative SSIs in patients undergoing emergency laparotomy in Bangladesh. Method: A prospective, case-control study was conducted at the Department of Surgery, Jalalabad Ragib-Rabeya Medical College & Hospital, Sylhet, Bangladesh, from June 2023 to July 2024. A total of 100 patients undergoing midline exploratory laparotomy were randomly assigned to either the case group (subcutaneous suction drain) or the control group (simple skin closure). Data on demographics, co-morbidities, and surgical outcomes were collected. The primary outcome was the incidence of SSIs, with secondary outcomes including hospital stay duration and other complications. Statistical analysis was performed using SPSS version 22. Results: The SSI rate was significantly lower in the subcutaneous suction drain group (10%) compared to the simple skin closure group (42%). The average hospital stay was also significantly shorter for the subcutaneous suction drain group (8.84 days) versus the simple skin closure group (11.20 days). Co-morbidities such as hypertension and diabetes showed no significant difference between groups. Conclusion: The use of subcutaneous suction drains significantly reduces the incidence of SSIs and shortens hospital stays after emergency laparotomies. These findings support the implementation of subcutaneous suction drains as a beneficial practice in surgical management, particularly in resource-limited settings.

Total Ankle Arthroplasty Incision Management: What Matters? A Systematic Review

Modern advancements in total ankle arthroplasty techniques and implants have increased the popularity of this treatment for ankle osteoarthritis. The preeminent approach for ankle replacement involves an anterior incision, however, wound complications with this approach provide a persistent challenge to surgeons. The present study was conducted to synthesize current data on ankle replacement wound complications via an anterior approach. A systematic review was completed including studies published from 1993 to present that employed an anterior approach and had precise criteria for wound healing and revisions. Twenty-nine studies, with level 3 to 4 evidence and moderate to serious bias, were included for a total of 6,986 ankle arthroplasties. The rate of wound healing without any complication was 90.38%. Minor dehiscence occurred in 6.00% of cases, while major wounds or infections occurred in 3.62%. Across 2,966 implants, the rate of major wounds or infections decreased from 7.03% before 2013 to 4.75% after 2013 (p = 0.034). Limited comparisons involving simple suture closure to various adjunct wound management techniques including negative pressure wound therapy, 2-octyl cyanoacrylate, platelet-rich plasma, dehydrated human amniotic membrane allograft, non-invasive skin expansion strips, compression wound dressings, tranexamic acid, surgical helmets, tourniquets, ankle arthrodesis, and lateral approach ankle arthroplasty, yielded non-significant differences (p > 0.18). Therefore, contemporary techniques, patient selection, and current implants may be leading to better soft tissue healing. As ankle replacement continues to surge in popularity, further research is needed to evaluate causative factors in successful anterior incision healing. Level of Clinical Evidence3

Massive bleeding and perforation due to post-colectomy pan-enteritis with a significant response to biologic in a patient with ulcerative colitis: a case report

BackgroundPost-colectomy pan-enteritis in ulcerative colitis (UC) is very rare, but it is often severe and fatal. We present a case of massive bleeding and perforation due to post-colectomy pan-enteritis, which showed a significant response to biologics in a UC patient.Case presentationA 30-year-old woman with a 5-month history of pancolitis UC underwent subtotal colectomy with ileostomy and mucosal fistula for refractory UC. She was diagnosed with small bowel obstruction on postoperative day (POD) 8 and bowel bleeding was observed on POD18. Reoperation was performed for bowel obstruction and bleeding on POD20. Intraoperatively, adhesive small bowel obstruction in the ileum and multiple erosions and ulcers with perforation were observed throughout the small bowel. We diagnosed post-colectomy pan-enteritis, and jejunostomy, lavage, adhesiolysis, and a simple closure of the perforated ileum were performed. High-dose steroid therapy for pan-enteritis was administered immediately after reoperation, and infliximab was administered because of worsening bleeding on day 3 after reoperation. Bleeding decreased one day after biologic administration and bleeding completely disappeared on day 10 after biologic administration. Specimens obtained from the terminal ileum at colectomy showed a normal ileum without inflammation and villus atrophy, while specimens from the perforated ileum showed congestion, villous atrophy, epithelial erosion, and mononuclear cell infiltration. No cryptitis, crypt distortion, or basal plasmacytosis (common characteristics in UC) were observed in either specimen.ConclusionAn early diagnosis and intervention are important for post-colectomy pan-enteritis, and infliximab may be effective. Post-colectomy pan-enteritis with a multiple ulcer phenotype has different histological characteristics from UC and may have a different pathogenesis.

Diagnosis and surgical treatment of obturator hernia in the recent decade with long-term follow-up: A single center experience.

Obturator hernia (OH) is a rare and dangerous disease that can lead to life-threatening consequences, and pelvic computed tomography (CT) is widely used for its diagnosis. There is no consensus regarding the surgical approach and repair methods. Retrospective analysis of the clinical and follow-up data of 15 cases of incarcerated hernias patients admitted to the Department of General Surgery, affiliated to Taicang Affiliated Hospital of Soochow University, from January 2011 to December 2022. OH could be precisely diagnosed with pelvic CT scan, except for occult OH and non-strangulated OH. Thirteen patients underwent emergency surgery, with a total complication rate of 76.9% and no mortality. Ten patients underwent open surgery, and 3 patients underwent laparoscopic surgery, which had advantages in terms of total cost and postoperative hospital stay (P < .05). Emergency patients all underwent simple peritoneal closure, and hernial sac excision was simultaneously performed in 6 of them. A recurrence (7.7%) was detected at 38 months after the first operation. There was no statistically significant difference between the 2 tissue repair methods in terms of recurrent rate. Pelvic CT can be used as a gold standard for the diagnosis of incarcerated OH, but it has limited value in occult OH and non-strangulated OH. Laparoscopic surgery is recommended for patients with a short onset time and no abdominal physical signs. Tissue repair is sufficient for incarcerated OH and hernial sac excision may be unnecessary.

Surgical approach for a refractory enterocutaneous fistula by combining laparoscopic surgery and a planned open conversion: a case report

BackgroundAn enterocutaneous fistula (ECF) is defined as an abnormal communication between the gastrointestinal tract and skin. ECFs are rarely encountered in clinical practice, yet are frequently difficult to treat. Few reports exist regarding the surgical techniques for the treatment of an ECF. Therefore, we report a case of refractory ECF with concomitant severe adhesions, in which we performed combined laparoscopic adhesiolysis and planned open conversion.Case presentationA 57-year-old female patient underwent a laparotomy for an ovarian cyst in her 20s. At 46 years, adhesiolysis without bowel resection was performed for adhesive small bowel obstruction (SBO). However, her symptoms did not improve. Eighteen days postoperatively, she underwent a reoperation and jejunostomy. An ECF developed post-reoperation; therefore, stoma closure and radical surgery for the ECF were planned. Due to the severe adhesions, only stoma closure was performed, based on intraoperative assessments. The patient was subsequently referred to our hospital. First, skin care around the fistula was provided during an outpatient visit. Appropriate sizing of the stoma pouch was performed, to improve erosions and ulcers. Thereafter, debridement of the perifistula skin and simple closure of the ECF outlet were attempted; however, the ECF recurred shortly thereafter. After 8 years of regular skin care, with the ECF remaining stable, however, manifesting as symptomatic SBO, she underwent laparoscopic adhesiolysis. This procedure was initiated in the epigastric region, where relatively fewer adhesions were anticipated. Post-open conversion, partial resection of the small intestine at four locations, including the fistula site, was performed. Postoperatively, jejunal edema and peristaltic dysfunction, due to narrowing of the superior mesenteric artery occurred. Regular drainage by percutaneous endoscopic gastrostomy was required. However, she improved and was discharged 3 months post-operatively. Three years post-operatively, the ECF and SBO did not recur.ConclusionsWe reported a case of refractory ECF in which we were able to safely perform surgery, by combining laparoscopic adhesiolysis and a planned open conversion. Therefore, the surgical approach used in this case may be an option for securing a safe surgical field, while avoiding collateral damage.

Complications of chest wall around malignant tumors: differences based on reconstruction strategy

BackgroundMalignant chest wall tumors need to be excised with wide resection to ensure tumor free margins, and the reconstruction method should be selected according to the depth and dimensions of the tumor. Vascularized tissue is needed to cover the superficial soft tissue defect or bone tissue defect. This study evaluated differences in complications according to reconstruction strategy.MethodsForty-five patients with 52 operations for resection of malignant tumors in the chest wall were retrospectively reviewed. Patients were categorized as having superficial tumors, comprising Group A with simple closure for small soft tissue defects and Group B with flap coverage for wide soft tissue defects, or deep tumors, comprising Group C with full-thickness resection with or without mesh reconstruction and Group D with full-thickness resection covered by flap with or without polymethyl methacrylate. Complications were evaluated for the 52 operations based on reconstruction strategy then risk factors for surgical and respiratory complications were elucidated.ResultsTotal local recurrence-free survival rates in 45 patients who received first operation were 83.9% at 5 years and 70.6% at 10 years. The surgical complication rate was 11.5% (6/52), occurring only in cases with deep tumors, predominantly from Group D. Operations needing chest wall reconstruction (p = 0.0016) and flap transfer (p = 0.0112) were significantly associated with the incidence of complications. Operations involving complications showed significantly larger tumors, wider areas of bony chest wall resection and greater volumes of bleeding (p < 0.005). Flap transfer was the only significant predictor identified from multivariate analysis (OR: 10.8, 95%CI: 1.05–111; p = 0.0456). The respiratory complication rate was 13.5% (7/52), occurring with superficial and deep tumors, particularly Groups B and D. Flap transfer was significantly associated with the incidence of respiratory complications (p < 0.0005). Cases in the group with respiratory complications were older, more frequently had a history of smoking, had lower FEV1.0% and had a wider area of skin resected compared to cases in the group without respiratory complications (p < 0.05). Preoperative FEV1.0% was the only significant predictor identified from multivariate analysis (OR: 0.814, 95%CI: 0.693–0.957; p = 0.0126).ConclusionsSurgical complications were more frequent in Group D and after operations involving flap transfer. Severe preoperative FEV1.0% was associated with respiratory complications even in cases of superficial tumors with flap transfer.

Fingertip injuries: Does administration of antibiotics give benefits? A double-blind randomized controlled trial.

Adequate debridement and defect closure is an important treatment in fingertip injuries in addition to administration of antibiotic. However, administration of anitibiotics remains controversial whether it necessary for fingertip injuries that have been treated with adequate debridement and defect closure. The goal of study is to assess the differences of infection rate between subgroups with administration of antibiotics and without antibiotic in FTI treated by debridement and simple defect closure. The study design was a double-blind randomized clinical trial. Data collection was carried out at Cipto Mangunkusumo General Hospital, Jakarta and Tangerang Regency Hospital, Banten, in July 2022-February 2023. The target population of this study were adult patients with Fingertip injuries that treated by debridement and simple defect closures with antibiotics administration and without antibiotic. Infection was assessed at day-7, 14, and 21 follow-up. There were 31 FTI subjects with 41 fingers affected. The number of male subjects was 27 people and female subjects 4 people. The most affected finger was the little finger (12 fingers, 30.8%), with most type of Allen classification was type IV (18 fingers, 43.90%), most procedure performed was primary suture (24 fingers, 58.54%). 15 subjects randomized to antibiotic group and 16 subjects to no-antibiotic group. There was 1 subject of antibiotic group and 1 subject of no-antibiotic group has infection. There are no significant differences between two groups. There were no significant differences of infection rate between antibiotics administration and without antibiotic in FTI cases that treated by debridement and simple defect closures.

A simple RANS closure for wind-farms under neutral atmospheric conditions: Preliminary findings

Accurately predicting wind turbine wake effects is essential for optimizing wind-farm performance and minimizing maintenance costs. This study explores the applicability of the Sparse Regression of Turbulent Stress Anisotropy (SpaRTA) framework to develop a simple yet robust Reynolds-averaged Navier-Stokes (RANS) model for wake prediction in wind energy contexts. The framework introduces two correction terms into two-equation models, with k − ε model being utilized in the current study. One correction term resembles the residual of the Turbulent Kinetic Energy (TKE) equation, and the other corrects the deviatoric part of the Reynolds Stress Tensor (RST). The terms are calculated from high-fidelity measurement or simulation data, and symbolic regression is used to determine the model for these terms.In this study, Large Eddy Simulation (LES) data from a single turbine is used as the training dataset, and a sample pre-selection process is employed to discover a correction model efficiently. The derived model incorporates two terms based on Pope’s basis tensors and their invariants. The expression of the obtained model shows that it functions as a modification to the constant Cµ in the k − ε model. The model is evaluated by comparing its predicted velocity and TKE fields with the LES data used for the training. The model showed satisfactory performance in predicting both fields. Additionally, its generalizability is evaluated by testing it against a more complex six-turbine unseen case. The results indicate that the model effectively captures the velocity field and power output, but it tends to overpredict TKE, especially in the wake region.

Simple Trans Sternal Closure of the sternum Versus Figure of Eight Closure of The Sternum in Open Heart Surgery

Simple Trans Sternal Closure of the sternum Versus Figure of Eight Closure of The Sternum in Open Heart Surgery

Laparoscopic repair of a primary parahiatal hernia combined with gastric volvulus: a case report and literature review

BackgroundParahiatal hernias present a hernial orifice at the diaphragm that is adjacent to the esophageal hiatus, differing from the paraesophageal type of hiatal hernias. Although diagnostic imaging has advanced in recent years, diagnosing parahiatal hernias remains challenging. We herein report a case in which we performed laparoscopic surgery and intraoperatively diagnosed a parahiatal hernia.Case presentationA 67-year-old man presented to our hospital with difficulty eating, epigastric pain, and vomiting. We suspected a paraesophageal hiatal hernia. Laparoscopic surgery was performed, and a diagnosis of parahiatal hernia was made. We closed the hernial orifice with direct simple closure using nonabsorbable threads. The patient’s postoperative recovery course was reasonable, and he was discharged on the twelfth postoperative day.ConclusionsParahiatal hernias are rare, and a definitive diagnosis is difficult. Laparoscopic surgery can help accurately diagnose and treat patients presenting with the condition.

Characteristics and management of post-circumcision Urethrocutaneous Fistula: a retrospective study in surgical units in Cameroon.

Urethrocutaneous fistula (UCF) is one of the major complications of circumcision. The risk factors associated with UCF are not clear-cut but its repair remains a challenge for urological surgeons. The aim of this study was to highlight the epidemiological, and clinical features and outcomes obtained from the management of UCF in the context of a country with limited medical resources where ritual circumcision is widely practiced. From February 2010 to December 2022, 35 patients underwent surgical repair for post-circumcision UCF in two tertiary hospitals in Yaounde, Cameroon. Simple closure, Thiersch-Duplay-Snodgrass and Mathieu techniques were performed. The mean age of patients was 7.4 ± 4.1 years with a range of 2 to 21 years; the median age at circumcision was 24 months (12; 48). Most (95%) of circumcisions were performed by paramedical staff. The majority of patients (n = 26) consulted for a bifid stream, Three-quarters of fistulae were located at the corona. Small fistulae represented 74.28% (n = 26) of cases as opposed to large fistulae (25.71%). More than 70% of patients underwent a simple closure. The therapeutic results were satisfactory in 91.4% of cases (n = 32) after an average follow-up of 91.85 ± 51.92 months. There were no statistically significant differences between the patients with coronal fistula and patients with distal penile fistula concerning demographic, clinical and surgical characteristics. Urethrocutaneous fistula is a major and frequent complication of circumcision mostly practiced by non-qualified personnel on children aged 24 months. The usual presentation is micturition with a bifid stream occurring on average 3 months after circumcision. Coronal fistulas are the commoner location. Simple closure, Thiersch-Duplay-Snodgrass and Mathieu technique appear to be safe with the advantages of low recurrence rate. An accurate diagnosis with a timeframe respecting the principles of fistula surgery combined with regular follow-up is mandatory for good long-term results with a low recurrence rate. Further prospective studies on the factors affecting the formation of urethrocutaneous fistula should be performed to prevent this complication of circumcision.

Assessing the State of Training in Congenital Interventional Cardiology: A Global Survey of Program Directors.

This study aimed to evaluate the current state of congenital interventional cardiology training worldwide, with a focus on case volumes, competency assessment, and the need for ongoing mentorship during early career stages. A survey was conducted among program directors (PDs) of congenital interventional training programs across the globe. The survey gathered data on training pathways, case volumes, types of procedures performed, trainee competency assessment, and the role of ongoing mentorship. Of the 79 PDs who completed the survey, it was observed that training pathways and case volumes varied significantly, particularly between the United States and other countries. Most PDs reported an annual laboratory case volume of >500 congenital cardiac cases, with most cases being interventional. While trainees demonstrated competency in simple procedures (diagnostic cases, simple ASD closure), complex interventions (such as patent ductus arteriosus closure in premature infants) require ongoing mentorship for graduates. PDs recommended a minimum case volume of 400 total cases for trainees, including 250 interventional cases. In addition to case volumes, assessing trainee competency was deemed important, with clinical reasoning, judgment, skillset, teamwork, and complication management being key areas of evaluation. The study highlights the variability in congenital interventional cardiology training and the need for ongoing mentorship during the early career years. External mentorship programs, facilitated by national and international societies, are proposed to provide critical support for early career interventionalists thus enhancing patient care for congenital heart disease. Ultimately, the findings of this survey may serve as a framework for future training standards and guidelines in this specialized field.

Modulation of flow, heat, and mass transfer in turbulent double-diffusive convection

The present study addresses numerical simulations of the double-diffusive convection in a turbulent regime. The characteristic concentration and temperature Prandtl numbers (PrC = 700 and PrT = 7) correspond to the typical seawater properties. Here, we applied the Large-Eddy Simulation (LES) approach, with relatively simple subgrid turbulence closures of momentum, concentration, and temperature for the unresolved scales. The wall-resolved LES approach proved to work well on significantly coarser numerical mesh than used in recent Direct Numerical Simulation (DNS) studies of Yang et al. (2016) in the intermediate range of working parameters, 107 ≤ RaC ≤ 109, 0 ≤ RaT ≤ 106, which covers the quasi-Rayleigh-Bénard, fingering, and damping flow regimes. A good agreement between concentration and temperature Nusselt numbers is obtained. The instantaneous Nusselt numbers distribution revealed a significant impact of the imposed strong thermal stratification (RaT = 106) in comparison to the neutral case (RaT = 0).

A prospective observational study of gastrointestinal perforations following blunt trauma abdomen

Background: Blunt trauma abdomen often presents late leading to increased morbidity and mortality, therefore the challenges in management of such patients warrant a study in this area for early diagnosis and better outcomes. Methods: A prospective observational study was carried out at a government institute in Central India. All patients having blunt trauma abdomen with GI perforations were observed over 2 years wherein clinical presentation, time of presentation, diagnostic methods and the outcomes were the parameters studied. Results: Young men (21-30 yrs) were found to be the commonly injured group. Road traffic accidents were the most common cause of blunt trauma abdomen. We found that mechanism of injury is related to the outcome and high energy transfer injuries (76%) led to high morbidity and mortality. Abdominal pain with abdominal tenderness and guarding was the most common presentation. Chest X-ray showed free gas under diaphragm in 58%patients who underwent xray. Other modalities used were FAST (focussed abdominal scan for trauma) scan which showed hemoperitoneum. CT scan had 97% sensitivity in diagnosis. Jejunum was the most common site of perforation. Simple closure of perforation with peritoneal lavage was the most commonly performed operative procedure. Overall, 35 patients developed complications in the postoperative period, wound infection being the most common. Mortality in this study was 26%. Conclusions: Young men are the most commonly injured in road traffic accidents with jejunum being the commonest organ injured. High velocity trauma, late presentation, multi- organ injury worsens the prognosis hence early diagnosis becomes imperative for better outcome.

Choice of suture technique may mitigate figure-of-8 deformity in slide tracheoplasty

ObjectivesTo demonstrate varying degrees of immediate postoperative figure of 8 deformity following three different methods of tracheal suturing. Study designComparative ex-vivo study. MethodsA fresh, unfixed rabbit trachea was harvested and bisected at its midpoint. The posterior membranous trachea was excised from both segments to mimic the anatomy of complete tracheal rings following longitudinal release. A slide tracheoplasty was performed on the same tracheal segments as an internal control, using three different methods of closure: simple running, running horizontal mattress, and a modified baseball stitch. Endoscopic and external photographs were taken immediately following repair to document the effect of closure technique on external and endoluminal anatomy. ResultsA simple running closure, in which traveling occurs between needle passes, showed the greatest degree of postoperative figure of 8 deformity. A running horizontal mattress suture closure showed less deformity and a modified running closure, in which traveling occurs within needle passes, showed the least deformity. ConclusionsOur study suggests that a minor modification of standard running closure techniques may help limit the common figure-of-8 deformity often noted following slide tracheoplasty. Lay SummaryFigure of-8 deformity is a problem that can occur when repairing a narrow trachea referred to as tracheal stenosis. This deformity may be prevented using particular suture techniques which may decrease the likelihood that the trachea becomes blocked again following repair.

Review of surgical treatment of suprastomal collapse in tracheostomised children

Suprastomal collapse (SSC) is considered amajor late complication of paediatric tracheostomy and can be responsible for decannulation failure in up to 20% of tracheostomised children. Depending on the severity of SSC, surgery may be required. Various strategies and techniques are available, of which the treating with airway team should be aware. This article intends to summarise the aetiology of SSC, its classification, clinical presentation, and the gold standard diagnostic and therapeutic algorithms according to the current literature. Apanel of experts reviewed the available literature on SSC. Published evidence on the different surgical techniques and their advantages and disadvantages was reviewed in detail, and atreatment algorithm created. The gold standard diagnostic procedure for SSC is flexible transnasal laryngotracheoscopy in spontaneous breathing followed by microlaryngoscopy (MLS) under general anaesthesia. Two main types of SSC can be differentiated, which differ in terms of surgical treatment. Purely anterior SSC is usually treated by tracheoplasty using an anterior costal cartilage graft (ACCG). Simple closure of the tracheostomy or excision of SSC with apotassium-titanyl-phosphate (KTP) laser are also described as less invasive approaches. For anterolateral SSC, segmental tracheal resection with end-to-end anastomosis or tracheoplasty with ACCG represent promising treatment options. Tracheal reinforcement with absorbable microplates is also discussed in the literature. With both types of SSC and depending on severity and the age of the child, awatch-and-wait strategy should always be considered. Dynamic airway endoscopy in spontaneous breathing followed by MLS in general anaesthesia should always be performed before decannulation. It is particularly important to visualise all segments of the airway during spontaneous breathing. The decision regarding the best surgical option for each child is based on the type and localisation of SSC, as well as on the patient's medical and surgical history and age.

‘’Comparative outcome study between simple closure and flap technique in Pilonidal sinus disease’’

I have read the interesting article ‘’Comparative outcome study between simple closure and flap technique in Pilonidal sinus disease’’ by Dr. Ram Magar and Dr. Rupali Magar published in your journal on 15th March 2022. According to this valuable study; Limberg flap method has has been found to have better outcome with less wound infection, wound disruption, postoperative discharge and recurrence rate compared to simple closure group. And as stated, it is safe and easy procedure. So it is recommended that Limberg flap method should be used in the treatment of pilonidal sinus disease over other modalities.[1]&#x0D; In our 767 patients study group results, we had recommended Limberg Flap Repair Technique for surgical treatment of pilonidal sinus disease. This technique had an acceptable “short” ‘Return to Work Outcome’ when compared with open techniques. Also had the smallest postoperative infection rate and low recurrence rate.&#x0D; Still in our daily surgical practice, earlier healing, shorter return to work, lower rates of infection and recurrence are the major factors that make us to use Limberg Flap Repair Technique mostly. Moreover, it is easy, fast, and practical to apply.[2]

Sinus of Valsalva Aneurysm: Different Modes of Presentation and Techniques of Repair.

A sinus of valsalva aneurysm (SVA) is an asymmetrical dilatation of the aortic root located between the aortic valve anulus and the sino-tubular junction. Congenital weakness of the elastic lamina in the aortic media layer or trauma and infection as acquired events are the most principal causes of SVA. Presentation may be acute when rupture has occurred or SVA may be discovered fortuitously on echocardiography or CT scan when patients are examined because of unspecific chest pains, dyspnea or arrhythmias. Although endovascular treatment has been performed successfully in individual cases, surgical closure of the aneurysm aiming at preservation of the aortic valve whenever possible is the established procedure. This short report emphasizes the fact that individual treatment is required when SVA need to be operated, depending on the presentation, the location and the size of the finding. Surgery may consist of simple patch closure, bilateral tunnel closure (entry and exit) or more radical operation like Bentall in case the whole aortic root should be addressed. Overall results are excellent, independently of the clinical presentation (acute or elective) with a mortality approaching zero.

Four-Layer Wound Closure Technique with Barbed Sutures for Inframammary Fold in Mastopexy Augmentation.

The inframammary fold (IMF) is an important landmark in breast aesthetic surgery. In augmentation mastopexy procedures, secure and accurate placement of the IMF is essential to aesthetic outcomes and to allow the new IMF to heal in the correct position without displacement. The authors present a simple and efficient four-layer wound closure technique using barbed sutures for closure of the repositioned IMF in augmentation mastopexy procedures. This method was previously described by the first author for reset of the IMF in breast augmentation surgery and has been adapted to the longer IMF incision in augmentation mastopexy procedures. A retrospective review was undertaken of 335 patients who underwent bilateral breast augmentation mastopexy procedures with a Wise pattern technique at a single unit. The newly reset IMF was closed using barbed sutures and a four-layer closure technique. There were no cases of complications related to wound healing or wound dehiscence. One patient required explantation for an infected implant. The four-layer wound closure technique with barbed sutures provides a quick and efficient method for accurate closure of the newly reset IMF, with positive outcomes related to wound healing. Secure and accurate placement of the inframammary fold is crucial in augmentation mastopexy procedures. The use of a four-layer wound closure technique with barbed sutures provides an efficient method for accurate closure of the newly reset inframammary fold. This method was previously described by the first author for reset of the IMF in breast augmentation surgery and has been adapted to the longer IMF incision in augmentation mastopexy procedures. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A mathematical model of peer-instruction including stochastic uncertainty

A mathematical model of peer-instruction including stochastic uncertainty is presented. By using the master equation describing stochastic transition among different states, a stochastically modified version of Nitta’s peer-instruction model is obtained. It is shown that moment equations with a simple closure reproduce the expectation and the variance obtained by using direct numerical simulations of the resultant model. Such a mathematical model will provide insights to the real data beyond the standard statistical analysis.