Small Transverse Incision Research Articles

Macedo ileal catheterizable reservoir adding the scissors maneuver of channel continence: Long term follow-up

The Macedo ileal catheterizable channel was published in 2000 and consists of an enterocystoplasty with a catheterizable channel that precludes the need of the appendix for the efferent channel. After 25 years of experience with this technique, we decided to review our experience in a select subgroup of cases performed and followed exclusively by the author in a non-teaching hospital facility after the latest modifications of the procedure. Since 2008, we have refined our technique with the following modifications: small skin transverse incision instead of longitudinal one, with a semicircular flap for further stoma creation in the midline and importantly the scissors maneuver. This maneuver consists of crossing two 2cm rectus abdominis muscle flaps in the midline to create a neosphincter over the catheterizable channel. Follow-up was defined as the interval between the date of surgery and last visit to the clinic. We defined stoma continence if the dry interval between catheterization was 4hs. Early and late complications were reported as well as the reintervention rate. Additional procedures in association with bladder augmentation were also appointed. We have treated 49 patients. Indications were spinal dysraphism (71.4%), mainly myelomeningocele (65.3%), and others (PUV, exstrophy, anorectal anomalies). Urodynamic evaluation showed bladder pressure of high risk for upper urinary tract involvement (66%), urinary incontinence (24.5%), conversion of incontinent urinary diversion (3.8%), one exstrophy patient not considered (1.9%). Mean age at surgery was 88 months (7.3 years), 21 patients had additional surgeries in addition to Macedo ileal catheterizable channel: Macedo-Malone LACE procedure in 21 patients and bladder neck surgery to improve continence in 5 patients. Urinary stoma continence was 93.9% (46/49) after first surgery, one patient had a serous line valve revised, two patients still leak after 2h and await revision. Overall enterocystoplasty complications rate was 12.24% and consisted of urinary leakage in 3 cases and channel/stoma stricture in 3 cases. All patients treated for sphincteric deficiency associated with bladder reconstruction are continent per urethra. Urinary stoma revision for stricture was done in 2 cases and consisted on suprafascial approach and reanastomosis, one patient resolved with dilatation of the channel to the stoma. Mean follow up is 100 months (8.3 years). We confirmed in a long term follow-up based on face-to-face visits with 8.3 years mean follow-up that the Macedo procedure associated with the scissors maneuver is associated with 93.9% continence of the stoma. Overall complications rate was 12.24%. The cosmetic aspect with a small transverse incision and a midline stoma is another strength of the technique.

Endoscopic release of the carpal tunnel using the Agee technique modified by Neumann

Decompression of the median nerve by complete endoscopic release of the transverse carpal ligament (TCL) and the distal antebrachial fascia. Minimization of surgical trauma results in decreased postoperative morbidity and earlier return to work and daily activities. Symptomatic carpal tunnel syndrome. Revision surgery after open or endoscopic procedure, rheumatic diseases. Small transverse incision at the ulnar border of the palmaris longus tendon, and proximal to the distal wrist flexion crease. Exposure and incision of the antebrachial fascia, dilatation of the carpal tunnel and dissection of synovial tissue from the undersurface of the TCL. With the wrist in extension, the endoscopic blade assembly with integrated camera is inserted into the canal. Exposure of TCL and short incision in the middle portion. Gradually, dissection of the distal portion of the TCL then completion by retraction of the blade distally to proximally. Slightly compressive dressing, selfcare on day1 after procedure. More than 25years of experience, more than 8000 treated patients, and 3 documented cases with intraoperative lesions of the median nerve requiring revision. High acceptance and patient satisfaction in AQS1patient-reported surveillance.

Economic Reliable Arthroscopic Technique for Reduction and Fixation of Acute Acromioclavicular Joint Dislocation

Separation of the acromioclavicular joint (ACJ) is a common orthopaedic injury among athletes involved in contact sports and victims of motor vehicle accidents. ACJ disruptions are common in athletes. Treatment is guided by the level of injury; grade 1 and 2 injuries are managed nonoperatively. Grades 4-6 are managed operatively, whereas grade 3 is an area of controversy. Several operative techniques have been described to restore anatomy and function. We present a technique that’s safe, economic, and reliable in the management of acute ACJ dislocation. It allows intra-articular glenohumeral assessment and relies on a coracoclavicular sling. This is an arthroscopic-assisted technique. It entails a small transverse or vertical incision over distal clavicle 2 cm away from ACJ, which enables us to reduce the ACJ and maintain reduction with a k-wire, checked by the C-arm. Diagnostic shoulder arthroscopy is then performed to assess the glenohumeral joint. The rotator interval is liberated and the coracoid base is exposed, and PROLENE sutures are then passed anterior to the clavicle medial and lateral to the coracoid. It is the used to shuttle polyester tape and ultrabraid as a sling under the coracoid. A tunnel is then made in the clavicle, then one end of suture is passed through the tunnel whereas the other end remains anterior. Several knots are made to ensure it is secured, then the deltotrapezial fascia is closed as a separate layer.

Minimally Invasive Carpal Tunnel Release Using a Hook Knife through a Small Transverse Carpal Incision: Technique and Outcome.

Compared to the classic open technique, limited exposure techniques have the advantages of less scar pain, more grip and pinch strength, and earlier return to daily life. We evaluated the effectiveness and safety of our novel method of minimally invasive carpal tunnel release using a hook knife through a small transverse carpal incision. This study included 111 carpal tunnel decompressions in 78 patients who underwent carpal tunnel release from January 2017 to December 2018. We performed carpal tunnel release using a hook knife through a small transverse incision just proximal to the wrist crease under local infiltration of lidocaine with tourniquet inflation in the upper arm. All patients were tolerable during the procedure and discharged following the procedure on the same day. At an average of 29.4 months of follow-up (range, 12-51 months), all but one patient (99%) revealed complete or near complete symptomatic recovery. The average of the symptom severity score on the Boston questionnaire was 1.31 ± 0.30 and the average of the functional status score was 1.19 ± 0.26. The final mean Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH) score was 8.66 (range, 2-39). There was no superficial palmar arch injury or nerve injury of the palmar cutaneous branch, recurrent motor branch, or median nerve itself as a complication of the procedure. No patient showed any wound infection or wound dehiscence. Our carpal tunnel release using a hook knife through a small transverse carpal incision performed by an experienced surgeon is a safe and reliable method that is expected to have the benefits of simplicity and minimal invasiveness.

Effectiveness of Proximal Small Transverse Incision for Carpal Tunnel Decompression

Effectiveness of Proximal Small Transverse Incision for Carpal Tunnel Decompression

The Macedo-Malone antegrade colonic enema: A minimal invasive technique that precludes appendix use

Antegrade continence enema (ACE) is recommended for patients with fecal incontinence/constipation refractory to conservative management. The Malone ACE utilizes the appendix as a catheterizable channel whereas the Macedo-Malone (MM) precludes the use of the appendix. We aimed to illustrate the MM procedure. The left colon is brought out through a small transverse incision on the upper left abdomen and a 3-cm transverse flap in a tenia is created. A 12-Fr silicone Foley catheter is placed on the mucosal surface of the flap to allow creating a tubular conduit. After closure of the anterior wall colonic, the continence valve mechanism is produced by embedding the tube over a serous lined tunnel created by interrupted sutures. The distal portion of the tube is anastomosed into a V shape to the skin flap to avoid stoma stenosis. The advantage of this technique is the all-the time availability for not requiring the appendix which some authors prefer to use for urinary reconstruction. In a previous study, we have shown that the MM produces a high rate (89%) of fecal continence (Mean follow-up: 75 months). We are convinced that this procedure can be incorporated into fecal incontinence/constipation armamentarium.

Mini-open transverse flexor crease incision versus limited longitudinal palmar incision carpal tunnel release: A short term outcome study

ObjectiveTo compare the outcome of carpal tunnel release using the limited longitudinal palmar incision technique and mini open transverse flexor crease incision technique. Materials and methodslBetween October 2017 and September 2019, we performed Carpal Tunnel release procedures on 122 consecutive patients with unilateral idiopathic CTS. Patients in Group A (64 patients) had a palmar mini open longitudinal incision at wrist. Patients in Group B (58 patients) had a small flexor crease transverse incision. In the non palmar transverse incision group, we used a blunt ended facelift scissors to cut the flexor retinaculum after placing a dural retractor between the retinaculum and median nerve. The preoperative and postoperative (2 weeks,6 weeks,3 months, 6 months and 1 year) patient statuses were evaluated with the Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) scores, VAS, grip strength and return to work days. ResultsThe BCTSQ symptom severity scale and functional status scale showed significant improvement following surgery in Group B compared to Group A at 2 weeks,6 weeks and 3 months (p < 0.05). At 6 months and 1 year follow up, both the symptom severity and functional status scale were comparable in both the groups. Grip strength, pillar pain and scar tenderness showed significant improvement in transverse flexor incision group compared to longitudinal palmar incision group at 6 weeks and 3 months and were comparable later on. ConclusionWe conclude that the mini open transverse flexor crease incision technique using the conventional instruments is simple, safe and cost-effective mode of treatment of idiopathic CTS when compared to the limited palmar incision technique. Though the long term outcomes are comparable in both groups, the flexor crease transverse incision group patients had better pain relief, better cosmesis and shorter recovery period than the palmar incision group

35 Say no to pneumo: Mini-laparotomy myomectomy is the way to go

This video demonstrates how to perform a safe and efficient mini-laparotomy myomectomy utilizing a unique abdominal entry technique. Leiomyomas are the most common estrogen-dependent benign uterine tumors in women. In patients who desire future fertility or a uterine-sparing surgery, myomectomy is an option. This surgical procedure can be performed using abdominal, laparoscopic, or robotic assisted approach; however, the choice of surgical technique depends on tumor size, surgeon experience and patient preference. Although minimally invasive routes such as conventional and robotic laparoscopy for myomectomy are now readily performed, in patients with significantly large leiomyoma, these routes can prove challenging due to limited visualization, increased risk for bleeding, and longer operating times. If the minimally invasive route proves successful, surgeons are still left with the dilemma of how to remove the leiomyoma from the peritoneal cavity. Commonly, a mini-laparotomy incision is performed for leiomyoma extraction. Mini-laparotomy myomectomy has been described in the literature using a vertical skin incision or Maryland incision to obtain abdominal access. The following video demonstrate a case series displaying a 4-step strategy for mini-laparotomy myomectomy with large leiomyomas to include Step 1: Abdominal entry and optimizing visualization, Step 2: Preemptive measures to prevent excessive bleeding., Step 3: Leiomyoma extraction and morcellation technique, and Step 4: Closure of uterine defects and hysterotomy repair. We present a unique surgical technique using a transverse skin incision with a vertical fascial incision to perform mini-laparotomy myomectomy in large leiomyomatous uteri. Unlike previously described techniques, our method is particularly effective as it maximizes visualization without rectus muscle transection, decreasing postoperative pain while maintaining a desirable cosmetic result from the small transverse skin incision.

"Zipper" Concept for Designing Expanded Forehead Flap in Facial-Cervical Reconstruction.

Skin defect of the lower part of the face and neck is a severe condition for many patients with burn and traumatic injuries or skin lesions. The expanded forehead flap with anterofrontal temporal vessel pedicles has been widely used in lower cheeks, chin, and neck reconstruction. (In this study, we introduce a new concept- "Zipper concept" of the flap design.) The aim of this study is to evaluate the feasibility and outcome of using expanded forehead flap with a vertical incision with or without a small transverse incision in the central part. From March 2010 to September 2016, 27 patients who suffered from lower cheeks and chin skin defects were reconstructed by expanded forehead flap with anterofrontal temporal vessel pedicles. After the lesion was excised, the upper or the lower part of the flap was cut in half with a vertical incision with or without a small transverse incision in the middle part as needed for cheeks, upper lip or neck reconstruction, and the other part of the flap was remained to be one piece for chin reconstruction. All flaps survived completely without any congestion or necrosis. All patients achieved satisfactory results both functionally and aesthetically. A vertical incision with or without a small transverse incision in the central part of the expanded forehead flap with anterofrontal temporal vessel pedicles is a safe modification of the flap design. It is practical and could bring the expanded forehead flap to more indications.

A comparative study of carpal tunnel release through three kinds of small incision for the treatment of carpal tunnel syndrome

Objective To compare the clinical efficacy and complications of small transverse and longitudinal incision of the wrist, and the small longitudinal incision of the palm in the treatment of carpal tunnel syndrome (CTS). Methods From June 2015 to June 2018, 150 patients with CTS were diagnosed and treated. There were 50 cases of wrist small transverse incision, 50 cases of wrist small longitudinal incision and 50 cases of longitudinal incision at the root of the palm for carpal tunnel release. The visual analogue scale (VAS), BCTQ score, Kelly's evaluation of clinical efficacy, postoperative complications, neuro-electrophysiological parameters, two-point discrimination and basic operation conditions were compared in three groups at 1, 3 and 6 months after operation. Results There was no significant difference in VAS, BCTQ score and Kelly's evaluation of clinical efficacy and excellent rate between the three groups (P>0.05); the incidence of postoperative scar pain and overall complications in the wrist longitudinal incision group was significantly higher than that in the wrist transverse incision group and the longitudinal incision at the root of the palm (P 0.05). Conclusion The results of three kinds of small incision carpal tunnel release surgery are similar in the treatment of CTS, but the complications of longitudinal incision at the root of the palm and wrist small transverse incision for carpal tunnel release surgery are less. Key words: Carpal tunnel syndrome; Treatment outcome; Small incision; Release

Modified Stark's (Misgav Ladach) caesarean section: 15 – year experience of the own techniques of caesarean section

ObjectiveA 15-year-experience of the personal modification of Misgav Ladach (ML) caesarean section in relation to the Dörffler method. Study designA retrospective clinical randomized observational study included 822 transperitoneal cesarean sections: 557 were performed via modified ML (without bladder catheterization, small transverse fascial incision with muscular stretching and non-preparation of vesicouterine plica) vs. 265 Dörffler (Pfannenstiel – Kerr) method. ResultsPerioperative and postoperative complications were significantly more frequent in the Dörffler method (p < 0.0005) (perioperative hemorrhage, more frequent adhesions, plastic peritonitis in repeated caesarean sections, as well as two bladder lesions). Postoperative febrility, dehiscence and wound seroma were more frequent in the first study group (p < 0.0005). More frequent paralytic ileus, uroinfections and bladder atony, which we did not observe in our own technique (p < 0.0005). The use of antibiotics and analgesics was prolonged until the fifth postoperative day in the first group compared to the second group where it was reduced to only 10 % on the second day (p < 0.0005). Also, the incidence of anemia and the need for blood transfusions were higher in the first study group, as well as the need for revision behind caesarean section and two hysterectomies due to massive postoperative intraperitoneal and retroperitoneal bleeding (p < 0.0005). ConclusionOur fifteen-year study highlighted the importance of our own published modified ML caesarean section in minimizing technique of surgery and the reduction of perioperative morbidity and significantly faster recovery of operated patients in the current era of enormous caesarean section increase.

PO 18150 - Comparison between the open and minimally invasive repair techniques in acute Achilles tendon injuries

Objective: Our study compares the functional outcomes of patients who underwent open repair of the Achilles tendon with those of patients treated with the minimally invasive technique using the percutaneous Achilles repair system (PARS) over a 1-year minimum follow-up period and presents the complication rates for the 2 techniques. Methods: Between 2011 and 2016, 31 patients were reviewed; of these, 20 were included in the study (10 PARS X 10 open repair technique). Patients with chronic Achilles tendon rupture, insertional or bilateral, and patients with a history of surgery or previous ankle pathology that could mask functional outcomes were excluded from the study. The open repair technique was performed via a posteromedial incision to the ankle to repair the tendon and was combined with myotendinous transfer of the flexor hallucis longus tendon, which was fixed with a Biotenodesis screw. The minimally invasive technique was performed using the PARS of the company Arthrex through a small transverse incision at the site of the Achilles tendon rupture. Functional outcomes and complications were collected after at least 1 year of follow-up. Results: Both groups had similar American Orthopedic Foot and Ankle Society (AOFAS) scores (PARS: 95.3±5.1, open: 96.5±5.1; p=0.604), demonstrating similar functional outcomes. The PARS group had a higher number of complications than the open repair group (PARS: 20% x open: 10%), but the difference was not significant (p=0.383). Conclusion: For the treatment of acute Achilles tendon injuries, the PARS and open repair techniques had similar functional outcomes after 1 year of follow-up.

Initial Experience of Minimally Invasive Concomitant Aortic and Mitral Valve Replacement/Repair at a Tertiary Care Cardiac Centre of a Developing Country.

IntroductionMinimally invasive double valve replacement (DVR) surgery through a small transverse anterior thoracotomy is an alternate technique to sternotomy for concomitant aortic and mitral valve (AVR, MVR) surgery. The aim of this study was to evaluate the in-hospital and early outcomes of direct vision minimal invasive double valve surgery (DVMI-DVR) at a tertiary care cardiac center of a developing country.MethodsThis study was conducted at the National Institute of Cardiovascular Diseases Karachi, Pakistan from January 2018 to September 2018. Nineteen consecutive patients undergoing DVMI-DVR for aortic and mitral disease without any prior cardiac surgery were included in this study. For all procedures, access was obtained through small transverse anterior thoracotomy incision with wedge resection (Chaudhry’s Wedge) of sternum opposite to the third and fourth costosternal joints. Patients were observed during their hospital stay and the following variables were observed the length of hospital stay (LOHS), ventilator support, intensive care unit (ICU) stay, pain score, and mortality. The pain score was assessed using the visual analog scale (VAS).ResultsThe male/female ratio was 11:8 with a mean age of 35 ± 12 years with mean EuroSCORE of 6.6 ± 3.5%. The mean total bypass time was 129.8 ± 23.83 min (range: 98-181 minutes). The mean mechanical ventilation time was 3.16 ± 1.12 hours (range: 2-6 hours). The mean intensive care unit (ICU) stay was 41.84 ± 8.36 hours. The mean post-operative LOHS was 5.63 ± 1.12 days (range: 4-8 days). We had zero frequency of wound infection and surgical mortality. The mean pain score was 4.32 (on a predefined pain scale of one to nine with a high value indicating severe pain).ConclusionMinimally invasive DVR surgery is a safe and reproducible technique with comparable outcomes such as postoperative pain score (4.32 ± 2.05), ventilation time (3.16 ± 1.12 hours), ICU stay (41.84 ± 8.36 hours), and hospital stay (5.63 ± 1.12 days). In terms of mortality, operative times, ICU stay, and hospital stay, the minimally invasive DVR is at least comparable to those achieved with median sternotomy. Further prospective randomized studies are needed to validate our findings.

Comparison between the open and minimally invasive repair technique in acute Achilles tendon injuries

Objective: To compare the functional results of patients submitted to open repair of the Achilles tendon in relation to those treated with the minimally invasive technique using PARS, with a minimum period of 1 year, as well as the complication index of the two techniques. Methods: Between 2011 and 2016, 31 patients were reviewed, including 20 cases (10 PARS X 10 Open technique). Patients with chronic Achilles tendon rupture, insertional or bilaterial, patients with a history of surgery or previous ankle pathology that could mask the functional results were excluded. The open technique was performed through a posteromedial incision to the ankle, repairing the tendon associated with the myotendinous transfer of the flexor hallucis longus, which was fixed with a biotenodetic screw. The minimally invasive technique was performed with the PARS (percutaneous Achilles repair system) of the company Arthrex, through a small transverse incision on the site of rupture of the Achilles tendon. Functional outcomes and complications were collected after at least 1 year of follow-up. Results: Both groups presented similar AOFAS scores (PARS: 95.3 ± 5.1, Open: 96.5 ± 5.1, P=0.604), showing similar functional results. Regarding the complications, the PARS obtained a greater number of complications in relation to the Open technique (PARS: 20% X Open: 10%), but without statistical relevance (P=0.383). Conclusion: We conclude that for the treatment of acute Achilles tendon injuries, the PARS and Aberta techniques have similar functional results after 1 year of follow-up. Level of Evidence IV; Therapeutic Studies; Cases Series.

NEW STANDARDS IN THE TREATMENT OF AN OLD PATHOLOGY: MIOGENIC TORTICOLIS

Introduction: The diagnosis and timely treatment of congenital muscular torticollis with physiotherapy can avoid their sequence of craniofacial asymmetry, which is difficult to correct once they have been established1. Cases that do not respond to initial medical treatment benefit from surgery. Objectives: To identify the clinical and surgical characteristics of the pediatric population with surgical treatment for congenital torticollis. Methods: Descriptive and retrospective study, carried out in the Pediatric Unit of the Head and Maxillofacial Surgery Service of the Edgardo Rebagliati Martins National Hospital. The sample consisted of 30 pediatric patients, with surgical treatment for congenital muscular torticollis during the last 15 years, who fulfilled the inclusion and exclusion criteria, the patients' clinical histories were reviewed. The statistics used were descriptive. Results: The age range of patients&nbsp; was from 2 months to 10 years of age, the&nbsp; sex predominated was male , the most affected side was the right side, the surgical treatment consisted of myotomies of sternocleidomastoid muscle insertions through direct approach by small transverse incisions, the correction amount had no correlation with age or with the severity of the deformity, good results were obtained even in severe deformities. Conclusion: In all cases we achieved substantial improvement, without complications and with acceptable scars; The lateral column of the neck at the site of the sectioned muscle recovered its continuity, without perception of abrupt cut, depression or subsidence. We did not observe a correlation between the improvement achieved and the severity of the deformity, nor with the age of the patient at the time of surgery. Key words: Congenital torticollis; Myogenic torticollis; Myotomy. (source: MeSH NLM) &nbsp; DOI: 10.25176/RFMH.v18.n2.1281

Autologous Rectus Fascia Graft Interposition Repair of Urethrocutaneous Fistulae in Female-to-Male Metoidioplasty Patients

To describe our technique and outcomes using an autologous rectus fascia interposition graft for repair of recurrent urethrocutaneous fistulae (UCF) following metoidioplasty. A circumferential incision is made to the skin surrounding the UCF and carried to the level of the underlying subcutaneous tissues. The inner fistula skin edges are closed with a running 5-0 monofilament absorbable suture to obliterate the urethral side. The length of the urethral wound is measured and an appropriate sized rectus fascia graft harvested from a small transverse lower abdominal incision that is also used for concomitant percutaneous suprapubic tube placement. Prior to outer skin closure with a running 5-0 monofilament absorbable suture, the fascial graft is spread-fixed between the urethra and skin to avoid overlapping suture lines. A 10-French urethral catheter is removed after 10 days and the suprapubic catheter removed after 2-3 weeks. Three patients have undergone repair of recurrent UCF with this technique since February 2017. All patients had undergone metoidioplasty with a mean time to fistula occurrence of 3.2 months. Mean number of prior UCF repairs was 3.0. With a median follow-up since repair of 7.0 months (range 4-8), no patient has reported UCF recurrence. UCF following metoidioplasty is a difficult surgical complication. Fistula closure with interposition of autologous rectus fascia allows for separation of suture lines and encourages healing without extensive reconstruction.

Preservation of the nipple-areola complex in skin-sparing mastectomy for early breast cancer.

Skin-sparing mastectomy (SSM) enables a radical cure of breast cancer while overcoming the cosmetic issues related to surgery. We review our experience of performing SSMs and assess whether preservation of the nipple-areola complex (NAC) could have been an option for some patients who underwent SSM. The subjects of this retrospective study were women who underwent SSM that utilized four incision types; namely, the so-called tennis racket incision, a periareolar and midaxillary incision, an areola-sparing and midaxillary incision, and a small transverse elliptical incision. We assessed whether preservation of the NAC would have been an option in SSM, based on histologic examination of three serial cut surfaces of the specimen around the nipple, ruling out the option when evidence of the malignant lesion/s was found in at least one of the following locations: in the nipple, within a 1-cm radius from the base of the nipple, or within 1cm from the surface of the NAC. We performed 193 SSMs. The cumulative 10-year local disease-free survival rate was 98%, with 89% of patients reporting levels of satisfaction with the reconstructed breast, of excellent, very good, or good. We evaluated that 70 of the 193 procedures could have been performed as nipple-sparing mastectomy (NSM). The outcomes of SSM in this series were excellent and NSM might have been an option for about one-third of the patients.

Abstract A010: Interrogation of checkpoint inhibitors in bioluminescent orthotopic syngeneic models of hepatocellular carcinoma

Abstract Background: Hepatocellular carcinoma (HCC) is an aggressive disease with limited therapeutic treatment options. Checkpoint inhibitors are widely being evaluated in numerous cancers including HCC, but suitable preclinical models are required. Subcutaneous syngeneic models are widely used to evaluate the impact of immunotherapy on tumor growth and tumor-invading leucocytes (TILs). However, the tumor microenvironment of orthotopic models is more comparable to the patient as they form an organ-specific site, facilitate metastatic spread, and, in the case of syngeneic models, support immune and stromal component interactions. Bioluminescent imaging (BLI) enables noninvasive longitudinal monitoring of orthotopic tumor burden, allowing for optimal randomization, reduction of false positives, and continuous feedback supporting optimal treatment regimen mid-study. Here we describe the generation of bioluminescent variants of syngeneic hepatocellular carcinoma (HCC) cell lines and assess the impact of immune checkpoint therapy on orthotopic growth in the liver. Methods: Bioluminescent variants of syngeneic cell lines H22 and Hepa 1-6 were established by lentiviral transduction. Orthotopic models were established via direct implantation into the liver. Under anesthesia a small transverse incision was made below the xiphoid to expose the liver, and cells were injected in the upper left lobe of the liver. The liver was then carefully placed back into the abdominal cavity and sutured. Tumor growth was assessed by BLI twice weekly and at end stage (Spectrum CT; PerkinElmer). Response to sorafenib and immune checkpoint therapy was also evaluated and TIL infiltration was assessed by FACs analysis and IHC. Results: The success rate of tumor transplantation into the liver was 100% as confirmed by both in-life imaging and ex vivo imaging at termination. Hepa 1-6 appeared to grow within the parenchyma of the liver whereas H22 grew within the liver as well as ascites. Real-time quantification of tumor size in response to treatment with sorafenib and check point inhibitors was correlated with alpha-fetoprotein (AFP) and end-stage tumor burden. Differences in TIL infiltration as detected by FACs and IHC were observed as well as stromal and blood capillary infiltration. Conclusions: The growth of bioluminescent HCC syngeneic models Hepa 1-6 and H22 was established to enable the evaluation of standard-of-care agents such sorafenib as well as immunotherapeutic agents. The liver microenvironment influences the orthotopic tumor growth and TIL infiltration, which requires characterization by both FACS and IHC in order to understand the relevance and utilization of such models. Citation Format: Nektaria Papadopoulou, Louise Wainwright, Vicky Lacey, Jane Wrigley, Jamie Wood, Sumanjeet Malhi, Louise Woolley, Jason King, Simon Jiang, Rajendra Kumari. Interrogation of checkpoint inhibitors in bioluminescent orthotopic syngeneic models of hepatocellular carcinoma [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr A010.

A minimally invasive approach for open surgical thoracoabdominal aortic replacement: experimental concept for a novel surgical procedure.

We aimed to develop a simple, reliable, and timesaving technique for the therapy of thoracoabdominal aortic (TAA) aneurysms that are not suitable for endovascular repair. In this pilot study, we sought to combine the advantages of classic open vascular procedure with the use of endoscopic surgical tools and small skin incisions to develop a minimally invasive approach for TAA replacement. The following procedures were used: endoscopic exposure and closure of the lower intercostal arteries; small posterolateral thoracotomy and left retroperitoneal incisions to expose the anastomotic regions of the aorta; partial anticoagulation; passive bypass and sequential aortic clamping; tunnelling of the graft through the native aortic lumen (endoaneurysmorrhaphy) and open performance of vascular anastomosis. Five mixed-breed dogs (25-35 kg) underwent minimally invasive TAA replacement. All animals survived the operation without blood transfusion (lowest Hb = 5.5 mg/dl). Total operation time was 364 ± 46.3 min. Clamping times were 17.6 ± 3.2 min for proximal anastomosis, 33.2 ± 2.48 min for visceral patch and 11 ± 2.3 min for distal anastomosis. The pull-through procedure of graft through the native aorta was performed during the visceral clamp time. Surgical replacement of the TAA through small transverse incisions of the thoracic and abdominal wall is feasible and allows open performance of all vascular anastomosis with no leakage at any anastomotic site. Further experimental studies and clinical implementation are needed to establish the safety and long-term outcome of minimally invasive TAA replacement as a possible primary therapeutic tool for complex aneurysms that are not suitable for endovascular treatment and require open surgical repair.

Modified Interscalene Approach for Resection of Symptomatic Cervical Rib: Anatomic Review and Clinical Study

Cervical ribs have been reported to be present in about 0.5% of the general population, 10% of patients with cervical rib who are symptomatic usually have neurogenic symptoms, but some have arterial symptoms. In 1861, Coote was the first to excise a cervical rib through a supraclavicular approach and relieved the symptoms of thoracic outlet syndrome. In this study, we address the efficacy and safety of a modification to the supraclavicular approach for resection of symptomatic cervical ribs. The surgical team in collaboration with an anatomist performed cadaveric dissections of the posterior triangle of the neck in the Department of Anatomy, Ain Shams University. A prospective study was performed of 25 patients with moderate to severe neck or upper limb pain; this pain was resistant to medical treatment for at least 6 months. Preoperative cervical radiography showed cervical ribs. Pain was assessed by using the visual analog scale. Electrophysiologic tests were performed to confirm the diagnosis. In this study, we performed a modified supraclavicular interscalene approach with resection of the symptomatic rib and without resecting either of the scalene muscles or the first thoracic rib. A total of 25 patients were included in this study; the mean age was 36 years (± 12 standard deviation), and the mean follow-up period was 12.3 months. All patients had moderate (28%) to severe (72%) preoperative pain. Motor deficits were present in 6 cases (24%); Sensory manifestations were present in 80%. All patients had a relief of severe pain at the first postoperative visit in the first week. There were improvements in the motor power in 5 of the 6 patients who had preoperative motor deficit. A modified supraclavicular interscalene approach for resection of symptomatic cervical ribs has been shown to be effective in the treatment of neuralgic pain. Compared with other approaches, it proved to be less invasive, with small transverse incision and without resection of scalenus anterior muscle.