Small Transverse Incision Research Articles

Does size matter?

To the Editor, In 1995, I described a modified Cesarean Section (CS), the so-called “Misgav Ladach” method (1) which gained international usage, including both in Turkey (2) and in Germany (3). There are scores of publications from many countries, all showing without exception a notably shorter operative time, and fewer complications of wound healing and reduced hospital stay. Although all display these benefits, the results also demonstrate large statistical variations. These variations are probably due to the lack of standardization of the surgical method, as only studies using a standardized method enable comparison of outcomes among different surgeons and institutions (4). The opening of the uterus in the classical Misgav Ladach CS, is done by cutting a small transverse incision in the middle of the lower segment and stretching the opening bi-digitally, transversely. In this way, the resulted bleeding is minimal. This enables suturing the uterus in one layer and although controversial, one layer may result in less ruptures during repeated pregnancies (5). As the uterus contracts immediately after CS, suturing is used mainly for immediate hemostasis. The suture material cannot contract with the uterus therefore; the more suture material left behind the more foreign body reaction, which might result in increased pain, irritation to the bladder and a weaker scar. For many years, I was suturing the uterus with a one-layer continuous locking stitch (6), using an 80 mm needle, PGA size 1. Using a big needle enables stitching further away from the incision line resulting in excellent hemostasis with minimal steps and less suture material, rarely needing extra single hemostatic sutures. When using a smaller needle, the surgeon must stitch closer to the incision line, demanding more time and steps, and in case of suturing the uterus in one layer, this could result in the necessity for an additional second layer or single extra stitches for hemostasis. Standardization of CS is needed in order to be able to compare the outcome among different surgeons and institutions. Comparing outcome of surgeries even performed using the same standardized method but with different sized needles, might lead to different outcome and therefore inaccurate conclusions. Therefore, it seems that the size of the needle does matter and I highly suggest to routinely using a standardized-sized 80 mm needle.

Two-stage Repair With Long Channel Technique for Primary Severe Hypospadias

To introduce a 2-stage repair with long channel technique for primary severe hypospadias. Between March 2010 and November 2013, 16 children with primary severe hypospadias underwent 2-stage repair with long channel technique. The technique applied in the first stage was almost the same as Bracka 2-stage repair. The second stage was usually performed 6months later. A small transverse skin incision, distal to the meatal opening and about 1cm in length, was made. Dissection was carried out deep into the surface of corpora cavernosa and a plane between the subcutaneous tissue and corpora cavernosa was reached. A long channel between the subcutaneous tissue and corpora cavernosa was created from the para-meatus incision to the apex of glans. A rectangle, pedicle scrotal septal skin flap was elevated and tubularized into neourethra around a stenting tube. The neourethra was delivered through the subcutaneous channel and fixed at the apex of glans. The mean operation time of the first and second stages was 65 and 55minutes, respectively. The mean age at the first and second operation was 28 and 36months, respectively. The mean follow-up was 10months. No fistula, glans dehiscence, urethral stricture, and meatal stenosis were recorded. One scrotal surgical wound infection occurred after second stage and healed successfully with antibiotics treatment. The overall cosmetic and functional outcomes after second stage were excellent. Two-stage repair with long channel technique was applicable for primary severe hypospadias, with excellent short-term outcomes.

Free transplantation of autogenous palmaris longus tendon in the repair of cicatricial ectropion of lower eyelid

Treatment of cicatricial lower eyelid ectropion is often difficult and requires surgical intervention. Numerous techniques have been developed over the years to treat the cicatricial lower eyelid ectropion. This article describes an effective surgical technique using the free transplantation of autogenous palmaris longus tendon in the repair of cicatricial lower eyelid ectropion. The operation was performed with the patient under local anaesthesia. After the contracture of the lower eyelid skin or conjunctiva had been thoroughly released, a palmaris longus tendon graft was obtained through small transverse incisions along the non-dominant forearm. The graft is suspended between the medial canthal ligament and lateral orbital rim with proper tension. Then a local skin flap was transferred to cover the wound at the lower eyelid. In this study, 15 patients were treated using autogenous palmaris longus tendon between December 2008 and October 2012. At the 9–18 months of follow-up assessment, there were no major complications reported with any of the cases, and all have achieved good function and satisfactory appearance of the lower eyelid. However, five patients (33%) still had lagophthalmos, but it was in remission. In conclusion, free transplantation of autogenous palmaris longus tendon in the repair of cicatricial ectropion of the lower eyelid is an effective procedure for cicatricial ectropion, the functional and cosmetic results were satisfactory, the recurrence rate is low. Especially for the moderate and severe ectropion this method is a good choice.

Percutaneous flexor tenotomy for preventing and treating toe ulcers in people with diabetes mellitus

IntroductionThe purpose was to examine the effectiveness of flexor tenotomy in a modified technique to prevent and heal neuropathic and neuroischaemic pressure ulcers on the tip of the toe in claw- or hammer-toe deformities in people with diabetes. Patients and methodsA consequetive 4 years series of 38 patients was retrospectively studied. Percutaneous tenotomy on the superficial and deep flexor tendons was performed in 65 toes through a small transverse plantar stab incision just proximal to the web level. There were 16 (42%) patients with 27 ulcerated toes and 22 (58%) patients with 38 toes with impending ulceration. Ten patients had neuropathic ulcers and six patients had neuro-ischaemic ulcers. Sixteen patients (42%) had macrovascular disease. Ten (26%) had proliferative rethinopathy, 7 (18%) macroalbuminuria and 18 (47%) microalbuminuria. ResultsAll surgical incisions healed uneventfully. Twenty-five (93%) of the toe ulcers healed in median 21 days (range 7–224 days). Three patients had recurrence of the ulcer. There were no infections in the incisions or toe amputations. No patients treated with preventive tenotomy experienced toe ulceration. No complications were recorded in neuro-ischaemic ulcers. During the follow up period of median 31 months (range 2–48 months) 33 other ulcers were recorded in 18 patients (47%). One of these developed a transfer ulceration under the adjacent metatarso-phalangeal joint and another had a late pressure ulcer on a neighbouring toe. The other 31 ulcers were not related to ulcers treated with tenotomy. ConclusionTenotomy is a simple, safe and effective procedure for preventing and treating distal plantar neuropathic toe ulcers in claw toe or hammer toe deformities in people with diabetes with or without serious co-morbidity. The results suggest that tenotomy should be considered also in neuroischaemic ulcers.

Rapid Intravenous Induction of Anesthesia for Dilatation of Severe Post-Intubation Tracheal Stenosis with Rigid Bronchoscopy: Report of 100 Cases

Background : Rigid bronchoscopic dilatation is the lifesaving method for management of severe tracheal stenosis which is carried out under general anesthesia. However, this procedure is a challenging practice for both anesthesiologist and bronchoscopist because loss of airway control and sever hypoxemia can occur following induction of anesthesia. Inhalational induction with avoiding muscle relaxants and preservation of spontaneous breathing is commonly recommended in these patients. However, this technique needs a long time to reach the appropriate levels of anesthesia and may be associated with the risk of complete airway obstruction during airway manipulation. This paper describes our experience in using rapid intravenous induction of anesthesia for dilation of severe tracheal stenosis with rigid bronchoscopy. Materials and Methods : We conducted a retrospective chart review of one hundred patients with benign severe post intubation tracheal stenosis who underwent rigid bronchoscopy for dilation of stenosis using intravenous sodium thiopental and succinylcholine for induction of general anesthesia. Results : In 97 patients adequate airway was established immediately after induction of anesthesia with the first attempt of rigid bronchoscope. In one patient, because of local bleeding and mild hypoxemia the airway was managed by a 4 mm tracheal tube and following improvement of oxygenation, dilatation of stricture was successfully done with rigid bronchoscope. In second patient, after passing the first bronchoscope, due to risk of rupturing the trachea, a small transverse cervical incision was made on the trachea and a tracheal tube was inserted through it for patient’s ventilation and dilatation of stricture was managed safely with the rigid bronchoscopes. In the third patient, due to failure of passing the bronchoscope, the trachea was intubated with a 4 mm endotracheal tube and tracheal resection and anastomosis was done successfully. Conclusion : in patients with severe post intubation tracheal stenosis, rapid intravenous induction of anesthesia is a safe method for passage of rigid bronchoscope for dilatation of stricture. Careful planning and close cooperation of the anesthesia and surgical teams is critical for safe and successful conduction of this procedure.

Evaluation of the New Classification and Surgical Strategy for Myasthenia Gravis

The aim of this study was to discuss the new methods of clinical classification and staging of patients with myasthenia gravis (MG) proposed by our group and to summarize the experiences of surgical treatment of MG with a novel incision by cutting the sternum cross-sectionally at the second intercostal level. A retrospective analysis was made for the clinical data from the patients with MG who underwent thymectomy from July 1988 to May 2009. The surgical procedures were designed into three groups, a group with Osserman classification and median incision of the sternum (Group 1), a group with MGFA typing (Myasthenia Gravis Foundation of America) and a small transverse sternal incision at the second intercostal level (Group 2), and a group with new typing and a smaller transverse sternal incision at the second intercostal level (Group 3). Observation of the clinical typing and staging was made in the patients with myasthenia crisis. The parameters such as procedure duration in Group 2 and 3 was significantly lower than those in Group 1 (P < 0.05). The incidence of myasthenia crisis in Group 3 was significantly lower than that in Groups 2 and 3 (P < 0.05). The procedure with a smaller transverse sternal incision at the second intercostal level (Group 3) is a safer method for patients with MG. The combination of this procedure with the new typing and staging methods proposed by our group could facilitate the selection of operation indications and opportunity, resulting in the lower incidence of myasthenia crisis and mortality. Our new procedure is well deserved to be a preferential selection by other hospitals.

Original Technique for Penile Girth Augmentation Through Porcine Dermal Acellular Grafts: Results in a 69‐Patient Series

Although different techniques for augmentation phalloplasty have been reported in the medical literature, this issue is still highly controversial, and none of the proposed procedures has been unanimously approved. The aim of this study is to describe an innovative surgical technique for penile girth augmentation with porcine dermal acellular grafts, through a small transverse incision at the penile base, along the penopubic junction. Between 2000 and 2009, 104 patients were referred to our institution for penile enhancement. After a preoperative psychosexual consultation and a general medical assessment, 69 patients were deemed suitable good candidates for surgery. The average penis circumference was measured at the mid-length of the penis and was 8.1 cm (5.4-10.7 cm) and 10.8 cm (6.5-15.8 cm) during flaccidity and erection, respectively. All patients received penile augmentation with porcine dermal acellular grafts. Results evaluation of an innovative technique for penile girth augmentation through exogenous porcine grafts and small penobubic incision. Postoperative measurements were performed at 6 and 12 months. At the 1-year follow-up, the average penis circumference was 11.3 cm (8.2-13.2 cm, 3.1 cm mean increase) during flaccidity and 13.2 cm (8.8-14.5 cm, 2.4 cm mean increase) during erection. No major complications occurred in the series. Minor complications were resolved with conservative treatment within 3 weeks. Sexual activity was resumed from 1 to 2 months after surgery. The psychosexual impact of the operation was beneficial in the majority of cases. Penile girth enlargement with acellular dermal matrix grafts has several advantages over augmentation with autogenous dermis-fat grafts: the elimination of donor site morbidity and a significantly shorter operation time. With this approach, through a short dorsal incision at the base of the penis, the scar is concealed in a crease covered by pubic hair and thus hardly visible.

Anal function-preserving subtotal intersphincteric resection/partial external sphincteric resection with hybrid 2-port hand-assisted laparoscopic surgery (Mukai's operation) for very low stage I rectal cancer: A case report.

A 62-year-old male patient underwent endoscopic mucosal resection (EMR). Additional hybrid 2-port hand-assisted laparoscopic surgery (HALS) (Mukai'soperation) was performed for early rectal cancer located at the distal border of the rectum/below the peritoneal reflection(Rb) region [SM massive invasion/ly+/vertical margin (VM)X] via a small transverse incision, approximately 55mm long, at the superior border of the pubic bone. After the pelvic floor muscles were dissected by laparoscopy-assisted manipulation, transanal subtotal intersphincteric resection (ISR) was performed under direct vision, securing a margin of more than 15 mm distal to the EMR scar. Partial external sphincteric resection (ESR) was also performed to obtain an adequate VM at the posterior region of the EMR scar. After bowel reconstruction, the layers were sutured transanally and a temporary covering colostomy was created. The resected specimen contained no residual tumor cells without lymph node metastasis. At 3 months after the operation, digital examination revealed good tonus of the anal muscles without stricture. The patient is currently undergoing rehabilitation of his anal sphincter muscles in preparation for the colostomy closure. In conclusion, subtotal ISR combined with partial ESR may decrease the need to perform Miles' operation for T1/2 stage I rectal cancer located at the distal border of the Rb region.

Minimally Invasive Technique for Release of Dupuytren's Contracture: Segmental Fasciectomy through Multiple Transverse Incisions

A multitude of operative approaches have been described for treatment of Dupuytren's contracture. A less-invasive technique of segmental fasciectomies performed through multiple small transverse incisions is presented. Seventy-three digits in 37 patients were treated with segmental fasciectomies. The results of 34 digits in 14 patients are described with subsequent follow-up longer than 2years. Metacarpophalangeal joint extension improved from a mean of 32.5° to 2.2°, while proximal interphalangeal joint extension improved from 22.9° to 4.1°. Patients subjectively rated their surgical outcomes as excellent or good in 91.2% of cases. No recurrence of the disease was noted, though extension of the disease to adjacent digits was observed in three patients. Though this approach is technically demanding and requires the help of a skilled assistant, this preliminary study supports our contention that this less-extensive procedure allows excellent correction of contractures; results in mild postoperative pain; and permits a rapid return of finger flexion with satisfactory long-term results so far at 2-years follow-up.

Minimally invasive innominate artery transection for tracheomalacia using 3-dimensional multidetector-row computed tomographic angiography: report of a case

We successfully performed transection of the innominate artery in a patient with a neuromuscular disorder through minimally invasive access after confirming the anatomical relationships of the vessel using 3-dimensional multidetector-row computed tomographic angiography. A 16-year-old girl with spinal muscular atrophy type 1 had been on long-term mechanical ventilation with a tracheostomy. She had scoliosis and tracheomalacia. Bronchoscopy showed a flattened and narrow lower trachea and an anterior pulsatile compression by the innominate artery. She underwent transection of the innominate artery to prevent tracheoinnominate artery fistula formation. Based on preoperative 3-dimensional multidetector-row computed tomographic angiography images, the innominate artery was transected through a small transverse curvilinear skin incision just below the suprasternal notch and an oblique partial manubriotomy from the suprasternal notch to the first left intercostal space.

Carpal tunnel syndrome: treatment with small transverse incision

To evaluate the application of a limited transverse incision technique to treat the carpal tunnel syndrome, with concern to its safety and efficacy in the opening of the flexor retinaculum (FR). A prospective analysis of thirty FR release procedures performed on twenty-eight patients subjected to the proposed incision technique. Safety and total opening of the FR were evaluated through a questionnaire and an endoscopic inspection respectively. No major complications were observed. Two cases presented small local hematoma. One patient presented with transient neuropraxia of digital branch. In two of the first five cases, incomplete FR opening was identified during endoscopic revision with need of complementary opening. All patients reported relief of paresthesias and nocturnal pain symptoms. The technique was safely performed on the prospection group, no major complications were detected and the opening of FR was observed in the majority of the patients.

Sentinel lymph node biopsy in breast cancer: the node to recovery

The widespread adoption of sentinel lymph node biopsy to stage the axilla has led to decrease in arm and shoulder morbidity. Sentinel lymph node biopsy is suitable for patients with clinically/radiologically node negative invasive breast cancer and selected patients with DCIS (those with clinical/radiological mass or extensive lesions requiring mastectomy). The combined isotope-blue dye injection technique gives the best results. We inject the isotope intra-dermally preoperatively and blue dye dye subdermally after anesthetic induction into the tumour quadrant peri-areolar tissue. Lymphoscintiscan is not necessary but is useful during the learning phase. Sentinel node biopsy can be performed through a small transverse or vertical axillary incision (∼3 cm) appropriately placed to allow axillary lymph node clearance if needed.

Comparision of three methods in treatment of osmidrosis

Objective To compare the therapeutic effects of three operative procedures,removal of armpit skin,minimally-invasive aspiration and small transverse incision in the treatment of osmidrosis.Methods Retrospective review was conducted in the treatment of osmidrosis for near ten years.Three methods were compared in the indication,feature and effectiveness.Results A total of 459 cases (123 males and 336 females) of osmidrosis were treated with the three methods.Satisfactory rates of the three methods were 98%,96% and 97%.respectively.Recurrence was found in 7 cases.Conclusions Modified procedure of minimally invasive aspiration has advantages of quick recovery,less complications and satisfactory results.It is the first choice for patients with mild and moderate osmidrosis.Bat for male patients with severe or recurred osmidrosis,treatments are surgical removal of the skin with armpit hairs and suture method. Key words: Osmidrosis; Minimally invasive treatments; Comparison

A New Corrective Method for the Tanzerʼs Group IIB Constricted Ear: Helical Expansion Using a Free-Floating Costal Cartilage

The group IIB constricted ear, as defined by Tanzer, shows a short helical length and an accompanying deficiency of the upper antihelix or scapha, and a cup or tubular form. The author proposes in this article a new corrective method for the deformity. Ten ears in eight patients were corrected with the author's new method. Three small transverse skin incisions were made along the helix, and a subcutaneous helical tunnel was prepared through the skin incision sites. A piece of split eighth or ninth costal cartilage was inserted into the tunnel. In each case, two to four auxiliary procedures were performed to make an effective helical expansion, as follows: (1) the fasciocutaneous Grotting flap was transposed on an intentionally induced gap at the incision site of the otobasion superius; (2) a marginally based scapha skin flap was elevated and advanced toward the inserted helical cartilage; (3) to prevent an excessive widening of the inserted helical cartilage, an additional costal cartilage bar was inserted through the postantihelical tunnel and connected between points on the ascending and descending helices of the inserted cartilage; (4) to correct ear prominence, a 4-0 nylon mattress suture was placed between the descending helix and the conchal wall. All reconstructed ears showed well-expanded helices. The reconstructed ears in unilateral cases showed the same shape and size as their opposite normal ears on follow-up views. The presented method was relatively simple and safe, and offered consistently effective results.

Cervical necrotising fasciitis and descending mediastinitis secondary to unilateral tonsillitis: a case report

IntroductionCervical necrotizing fasciitis is an aggressive infection with high morbidity and mortality. We present a case of cervical necrotizing fasciitis and descending mediastinitis in a healthy young man, caused by unilateral tonsillitis with a successful outcome without aggressive debridement.Case presentationA 41-year-old man was admitted to our unit with a diagnosis of severe acute unilateral tonsillitis. On admission, he had painful neck movements and the skin over his neck was red, hot and tender. Computed tomography scan of his neck and chest showed evidence of cervical necrotizing fasciitis and descending mediastinitis secondary to underlying pharyngeal disease. He was treated with broad-spectrum intravenous antibiotics. His condition improved over the next 3 days but a tender and fluctuant swelling appeared in the suprasternal region. A repeat scan showed the appearance of an abscess extending from the pretracheal region to the upper mediastinum which was drained through a small transverse anterior neck incision. After surgery, the patient's condition quickly improved and he was discharged on the 18th day of admission.ConclusionLess invasive surgical techniques may replace conventional aggressive debridement as the treatment of choice for cervical necrotizing fasciitis and descending necrotizing mediastinitis.

V5 Minimal access right hemicolectomy – no ports!

Introduction: The recent trend towards minimal access surgery for colon cancer (particularly right‐sided cancer) implies that this type of surgery always requires laparoscopic assistance. We present a video which demonstrates that in selective cases a safe, adequate resection can be carried out through a small transverse incision.Methods: A retrospective review of prospectively collected data on all patients undergoing RH by a single surgeon was performed. Data was collected on age, sex, BMI, elective/emergency status, ASA grade, curative intent incision (traditional midline vs small transverse; &lt; 10 cm), and nodes retrieved, length of post hospital stay, complications and curative intent. Results are expressed as a median (range) and where appropriate compared using ANOVA.Results: Lymph node counts were similar in both groups, TI group 13(5–22) and MI group 12(3–22), P = NS. In those undergoing curative surgery, no positive margins were identified in either group.Conclusions: There is no difference in lymph node retrieval when a right hemicolectomiy is performed through a minimal access transverse incision as compared to a midline approach. We recommend that in appropriate cases right hemicolectomy can be carried out safely/adequately through a small transverse incision without the aid of laparoscopy.

Value of latissimus dorsi flap (LDF) in breast conserving surgery (BCS)

This paper describes a method of immediate breast reconstruction following conservative breast surgery. The technique is innovative in that axillary clearance, quadrantectomy and the harvest of the latissimus dorsi muscle are carried out through a small transverse axillary incision with no incision in the breast.

Radical treatment of axillary osmidrosis by subdermal excision of apocrine glands: a prospective study in 31 cases

Axillary osmidrosis is a troublesome and distressing problem. Medical treatment is only temporally effective. From March 2003 to November 2004, 36 patients with axillary osmidrosis (nine cases combined with axillary hyperhidrosis) have been treated by excision of the subcutaneous glands via a small transverse incision, of which 31 cases could be followed up for a minimum of 3 months (average 7.3 months). In terms of malodour elimination, 30 cases had good results, one had fair result, and none had a poor result. All patients reported significant reducing of sweating, especially those with hyperhidrosis. Postoperative complications were minor, including small haematoma (one axillae), small seroma (two axillae), and superficial epidermal necrosis (21 axillae) which were all spontaneously healed within a week. Twenty-nine (93.5%) patients were very satisfied with the procedure and two (6.5%) patients satisfied, with none regretful. The operation has the advantage of a high success rate in radical elimination of the malodour with minor complications.

Direct access to the carotid circulation by cut down for endovascular neuro-interventions

Background Not all vascular lesions of the brain that are amenable to endovascular treatment are safely accessible via the transfemoral route. We describe our technique of carotid cut down for endovascular access and present a couple of illustrative cases. The increasing number of neurosurgeons performing endovascular procedures, or collaborating with interventional neuroradiologists, suggests that this technique should be revived. Methods Through a small transverse neck incision at the level of the thyroid cartilage, the CCA, ICA, and external carotid artery are exposed. After obtaining vascular control with vessel loupes, a purse-string suture is placed in the CCA. Puncture of the artery in the center of the purse string is followed by navigation of a wire, and then a sheath, into the ICA. The neurointervention is then carried out. At the conclusion of the procedure, the sheath is removed from the CCA and the purse string tied to secure the artery. Results This technique has allowed us to successfully access the intracranial circulation in 6 patients with challenging anatomy. We present here 2 of the original cases leading to our increasing use of this technique. Conclusion Carotid cut down for direct puncture of the CCA is a viable option to gain access to the intracranial circulation when the transfemoral route seems difficult or dangerous.

Healing of abdominal incisional hernia in infant rats

Incisional hernia following major laparotomy in adult humans occurs in 5 per cent of cases. Spontaneous healing of such hernias does not occur. We have devised a model for producing abdominal wall incisional hernia in the rat by dividing the linea alba subcutaneously through a small transverse skin incision. In adult rats (n = 17), an incisional hernia formed and progressively increased in size over 32 weeks. In 3-week-old infant rats (n = 17), all developed herniation immediately. In eight rats, these hernias progressively increased. In three, the hernias were healed at the third week, but recurred at the fourth, eighth and 12th weeks, respectively. In the remaining six animals, the hernias healed spontaneously at 3 weeks and remained healed. A similar observation of spontaneous healing of incisional hernias in children has been reported in one clinical paper. This animal model provides a useful means of studying the clinical difference between adult and infant with respect to incisional hernia.