Small Vertical Incision Research Articles

Piezocision Through Computer-Guided Navigation.

Numerous surgical techniques have been developed as effective means to facilitate orthodontic treatment, but they may cause significant postoperative discomfort. Piezocision was established as a flapless and minimally invasive technique to accelerate orthodontic tooth movement by com- bining small vertical incisions and piezoelectric corticotomies. Computed tomography is combined with the Piezocision technique to fabricate CAD/CAM surgical guides to prevent iatrogenic damage. A method to combine computer-assisted dynamic navigation with Piezocision is introduced here. CBCT was combined with motion-tracking technology to allow real-time tracing of the piezoelectric instruments during the surgical procedure. This technique delivers the location of the piezoelectric knife in regard to roots and important anatomical structures to increase the safety and accuracy during corticotimies.

A study on displaced mid-clavicular fractures treated by titanium elastic nailing system (Tens)

Introduction: The mid shaft clavicle fractures account for 70-80% of all clavicular fractures. Intramedullary devices behave as internal splints that maintain alignment without rigid fixation. TENS provide a three point fixation within S-shaped clavicle and effectively control rotation, angulation and shortening.Materials and Methods: study included 21 patients aged between 18 to 60 years who underwent CRIF/ORIF with TENS for mid clavicular fractures in Department of Orthopedics, SMCH. Percutaneous nails are placed from medial to lateral direction. Entry point is 1 cm lateral to sternoclavicular joint. 5 to 10 mm longitudinal skin incision made 2mm medial to entry point in clavicle. In open approach a small vertical incision made at level of fracture. Post operative follow up done at postoperative day 10, 3 weeks, 6 weeks, 4 months, 6 months.Results: Timing of operation was 2 to 15 days from date of injury. Close reduction was done in 6 cases and open reduction required in 15 cases. DASH score was 5 -10 at 24 weeks and constant shoulder score was 95-100 at 24 weeks. Time for clinical union was 6 to 12 weeks and for radiological union was 12 to 14 weeks.Discussion: TENS are only indicated for OTA type A and B mid clavicular fractures. Diameter of nail should not be less than half of that of medullary cavity.Conclusion: Fixation of displaced mid clavicular fracture with TENS is technically demanding and minimal invasive, early functional recovery and 100% rate of fracture union. Study gives sufficient evidence of excellence of this procedure in OTA type A midclavicular fractures, preferably transverse or short oblique fracture.

Minimally invasive periodontics – A future landscape

Periodontal diseases are a heterogeneous group of diseases characterized by inflammation and the subsequent destruction of the tooth supporting tissue. Conventional periodontal regenerative procedures involving periodontal flaps for access are employed to improve short- and long-term clinical outcomes of periodontally compromised teeth. Minimally invasive therapeutic approaches with minimized incisions and trauma to the soft tissue have proven to be advantageous over the conventional therapy. This review focuses on four such techniques – PerioProtect, Tri-Immuno Phasic Periodontal Therapy, Subperiosteal Minimally Invasive Aesthetic Ridge Augmentation Technique (SMART) and Flapless technique for Bone Graft. PerioProtect is a non-invasive chemical debriding therapy that involves a customized tray for patients to help manage biofilms, growing in the spaces or pockets between teeth and gum tissue. Tri-immuno phasic therapy is minimally invasive technique, by William Hoisington, which allows clinician to go under the gum line and destroy anaerobic bacteria non-surgically. SMART was suggested by Kent et al. in which a small vertical incision is made in the alveolar ridge and bone graft injected under the periodontium. Flapless technique for bone graft is a non-invasive technique which involves scaling and root planing, and insertion of single grains of bone mineral through the crevicular space into the pocket until it is completely filled. These minimally invasive procedures offer an efficient, safe less traumatic alternative in the treatment of periodontitis. Keywords: PerioProtect, Tri-Immuno, Occlusal forces.

Structures at Risk in the Arthroscopic Brostrom-Gould Procedure: A Cadaver Study

Category:Ankle, Arthroscopy, Basic Sciences/Biologics, SportsIntroduction/Purpose:The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopaedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopaedic surgeons. Typically, this technique requires standard medial and lateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures.Methods:Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented.Results:The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens.Conclusion:Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

Comparison of Aesthetic Quality of the Final Scar in Abdominoplasty with Conventional and Mini Inverted t-Scar.

Background and objectives: Abdominoplasty is one of the most commonly performed cosmetic procedures. The excess skin in the conventional abdominoplasty is transversely excised and a single horizontal scar is formed. The mini inverted t-scar abdominoplasty is a modification of the “Fleur-de-lis” technique and involves the use of a small vertical incision in comparison to the long vertical incision. The aim of this technique is to lower the position of the final abdominal scar instead of addressing the horizontal laxity. In this study, we have compared the aesthetic satisfaction, width and the position of the scar with conventional abdominoplasty and mini inverted t-scar abdominoplasty. Materials and Methods: Thirty patients undergoing abdominoplasty and breast reconstruction with transverse rectus abdominis flap (TRAM) and deep inferior epigastric flap (DIEP) were included in the study. In 15 patients, abdominal closure with the conventional transverse scar was performed. In the remaining 15 patients, closure with a mini inverted t-scar was performed. Scar width, scar height and satisfaction scores were evaluated in both groups. Results: Scar widths, scar heights and patients’ and as well as surgeons’ satisfaction scores were better in the mini inverted t-scar group than the conventional group. Conclusions: The visibility of the vertical scar alone should not be a reason to avoid mini inverse t-scar abdominoplasty. Mini inverted t-scar can be an option to achieve a better hidden high-quality scar.

Anatomical structures at risk in the arthroscopic Broström-Gould procedure: A cadaver study

BackgroundThe Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopedic surgeons. Typically, this technique requires standard anteromedial and anterolateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures. MethodsTen fresh-frozen below-knee cadaver specimens were used. The location of the accessory lateral portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented. ResultsThe average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens. ConclusionArthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

Intracorporeal Circular Stapled Esophagojejunostomy Using Conventional Purse-String Suture Instrument After Laparoscopic Total Gastrectomy.

An optimal alimentary tract reconstruction technique after laparoscopic total gastrectomy (LTG) remains controversial. The authors developed a new simple technique for intracorporeal esophagojejunal anastomosis that employs a conventional purse-string suture instrument (PSI) and circular stapler. From May 2014 to April 2016, 41 consecutive patients with gastric cancer underwent LTG in the author's institution. Intracorporeal esophagojejunal anastomosis using the following method was attempted for all patients. After total gastrectomy was completed laparoscopically, a small vertical incision (about 40 mm) was created at the left midclavicular line and retracted by a wound retractor. An anvil of a 25 mm circular stapler was introduced into the abdominal cavity. Then a previously prepared surgical glove, which was cut open at the thumb and the little finger through which the two hand shafts of the PSI were passed separately and sealed by ties, was attached to the wound retractor to maintain airtightness, and the PSI was introduced into the abdominal cavity. The following procedure was similar to conventional open surgery except that it was performed under laparoscopic vision. Intracorporeal esophagojejunal anastomosis was performed successfully for all 41 patients. No case required extension of the initial incision for difficulties during anastomosis. The mean operation time was 245 minutes, and the mean time for the purse-string suture and anvil placement was 15 minutes. Tumor-free margins were achieved in all 41 patients. There were no anastomosis-related complications or other major surgical complications. With the described method, intracorporeal esophagojejunal anastomosis can be performed easily and safely.

Airway collapse after attempt of intubation in a patient with pharyngeal mucosal space abscess: a case report.

Background: Pharyngeal mucosal space abscess is a very rare deep neck infection. Due to the anatomical relationship with the pharyngeal airway, patient may have some signs and symptoms of upper airway obstruction. Decision in airway management is important to reduce morbidity and be able to drain the abscess. Objective: To report a potential devastating airway complication in a patient with pharyngeal mucosal space abscess during intubation. Method: A patient with pharyngeal mucosal space abscess was treated and served as basis of this report. Results: After several attempts of oral intubation, the abscess was ruptured and caused acute upper airway obstruction. Surgical cricothyroidotomy was made, and converted to tracheotomy later to secure the airway. Abscess finally drained through vertical incision on the pharyngeal lumen without further complication. Conclusion: Serial aspirations should be considered in case of pharyngeal mucosal abscess to eliminate risk of ruptured abscess and airway collapse from intubation procedure. In case of successful intubation, small vertical incision on the pharyngeal wall might make adequate drainage without any scar post-operatively.

Minilaparotomy Approach Employing a Küstner Incision for Rectal Cancer Resection: Report of Three Cases

A minilaparotomy approach ( 7 cm) for colorectal cancer resection is feasible and safe. Such minilaparotomy generally employs a small vertical incision. A low transverse abdominal incision (a Kustner incision) has been shown to be associated with cosmetic advantage, less postoperative pain, and fewer wound-complications than the midline incision. We report three cases (75-year-old female, 64-year-old male, and 74year-old female) who underwent anterior resection of rectal cancer via a minilaparotomy approach employing the Kustner incision. No handport or laparoscope was used. The median body mass index was 18.9 (range, 18.3-19.3) kg/m 2 . The rectal tumors were located in the rectosigmoid and the upper rectum. There were no intraoperative complications. The median operating time and operative blood loss were 160 (range, 159-162) min and 80 (range, 30-90) ml, respectively. All tumors were curatively resected. The patients quickly returned to normal function without morbidity or mortality. No patients developed wound-related complications. During a median follow-up period of 27.4 (range, 26.829.0) months, all patients are alive without tumor recurrence. In addition, neither incisional hernia nor nerve damage developed. We conclude that the minilaparotomy approach employing a Kustner incision is a less invasive and an attractive method with a cosmetic advantage for rectal cancer resection in selected patients. ACTA MEDICA NAGASAKIENSIA 53: 51－54, 2008

Surgical Approach for Removal of Nonarticular Base Sesamoid Fragments of the Proximal Sesamoid Bones in Horses

To describe a surgical approach for the removal of nonarticular base sesamoid fragments in performance horses and to report the outcome. Retrospective study. Horses (n=11), 7 months to 10 years of age, with lameness because of nonarticular base sesamoid fragments. Lameness was localized to the metacarpophalangeal/metatarsophalangeal region by clinical examination or response to diagnostic local anesthesia. Radiographs confirmed the diagnosis of a nonarticular base sesamoid fragment. Surgical removal was performed with an incision over the base of the affected sesamoid through the digital flexor tendon sheath. After identifying the fragment with the aid of needles, a small vertical incision was made in the straight distal sesamoidean ligament (SDSL) and the fragment was freed from its attachments and removed. Six months convalescence and rehabilitation was prescribed for all horses. Eleven horses had 16 nonarticular fragments of the base of the proximal sesamoid bones. Eleven (69%) fragments occurred in the forelimbs with the right front (82%) and medial sesamoid (73%) more commonly affected. Horses were treated by surgical fragment removal. In horses with follow-up, 9 of 10 returned to their intended use. Surgical removal of nonarticular base sesamoid fragments can be accomplished through a palmar/plantar approach through the digital flexor tendon sheath and SDSL. This "keyhole" approach minimizes damage to the distal sesamoidean ligament attachments to the sesamoid base and allows some horses to return to their intended use. Surgical removal of nonarticular base sesamoid fragments should be considered in horses with performance-limiting lameness as a result of the fragment.

Mitochondrial Uncoupling Protein-2 Mediates Steatotic Liver Injury following Ischemia/Reperfusion

Steatotic livers are not used for transplantation because they have a reduced tolerance for ischemic events with reduced ATP levels and greater levels of cellular necrosis, which ultimately result in total organ failure. Mitochondrial uncoupling protein-2 (UCP2) is highly expressed in steatotic livers and may be responsible for liver sensitivity to ischemia through mitochondrial and ATP regulation. To test this hypothesis, experiments were conducted in lean and steatotic (ob/ob), wild-type, and UCP2 knock-out mice subjected to total warm hepatic ischemi-a/reperfusion. Although ob/ob UCP2 knock-out mice and ob/ob mice have a similar initial phenotype, ob/ob UCP2 knock-out animal survival was 83% when compared with 30% in ob/ob mice 24 h after reperfusion. Serum alanine aminotransferase concentrations and hepatocellular necrosis were decreased in the ob/ob UCP2 knock-out mice when compared with ob/ob mice subjected to ischemia. Liver ATP levels were increased in the ob/ob UCP2 knock-out animals after reperfusion when compared with the ob/ob mice but remained below the concentrations from lean livers. Lipid peroxidation (thiobarbituric acid-reactive substances) increased after reperfusion most significantly in the steatotic groups, but the increase was not affected by UCP2 deficiency. These results reveal that UCP2 expression is a critical factor, which sensitizes steatotic livers to ischemic injury, regulating liver ATP levels after ischemia and reperfusion.

Modulation of early angiogenesis by nitric oxide

undergone surgical placement of bone anchorage devices for orthodontic treatment. A total of 37 devices have been placed to date. In three cases, maxillary IMF screws were placed bilaterally in order to provide orthodontic anchorage. In the remaining 16 patients, specialized bone anchorage devices were used. Data collection was carried out during a retrospective review of each patient’s record, preoperative and postoperative radiographs, and patient and surgeon questionnaires completed during the perioperative period. Results: All participating surgeons rated the surgical procedure as very easy to moderately easy. The most challenging aspect of the surgical procedure was related to retraction during the placement of devices through small vertical incisions. Postoperative morbidity was characterized by minimal to mild pain and moderate degree of swelling. Postoperative complications included mucosal inflammation around the device (2 implants), fracture of one device, and failure of the monocortical screws securing the device (2 implants). Conclusion: The use of skeletal fixation devices for anchorage appears to be a promising adjunctive treatment for specific orthodontic indications. Our preliminary surgical experience has revealed easy surgical placement, minor postoperative morbidity, and a low rate of postoperative complications related to the implants.

Incompetence of the gastrocnemius vein

The veins of the popliteal fossa are more complex than is generally realised. It is frequently taught that the short saphenous vein need only be divided deep to the popliteal fascia. However, the pattern and level of termination of the short saphenous vein shows wide variation. Sometimes, the short saphenous vein is normal and the pathology involves other veins. The 'vein of the popliteal fossa' may sometimes be present as a large tortuous varicosity and pierce the fascia to become superficial at the back of the knee. Incompetence of a gastrocnemius vein, usually the medial, may cause swelling and discomfort within the calf yet nothing is apparent. Awareness may be precipitated by attempting to wear tight fitting boots or trousers when the difference in calf circumference is recognised yet there is no ankle oedema. Next a venous flare or dilated venules appear over a perforator site, usually the mid-calf perforator, but sometimes the Boyd's perforator, filling the posterior arch tributary of the greater saphenous vein. Incompetence of a gastrocnemius vein is suggested by the history and clinical examination. Reflux is demonstrated by Doppler ultrasound and accurately localized by duplex ultrasound with colour-flow imaging. The anatomy is clearly visualized by venography.Large gastrocnemius veins are seen in athletes and ballerinas with well-developed calf muscles and such veins are physiological and should not be interrupted. It is imperative that reflux is demonstrated before surgical treatment is offered. Treatment involves ligating the incompetent gastrocnemius vein through a small incision over the popliteal fossa. If the mid-calf perforator is also incompetent it is divided deep to the fascia through a small vertical incision and the fascial defect closed. The distal short saphenous vein may be removed by partial stripping and any tributaries removed by phlebectomies using Oesch hooks. Strong below-knee stockings are worn for a month following this surgery.

Antegrade extraperitoneal approach to radical cystectomy and ileal neobladder.

We describe a new operative technique for the surgical treatment of bladder cancer. Male patients with invasive bladder cancer were managed by radical cystoprostatectomy using a technically different approach than the conventional method. The main feature of this method includes a small vertical incision between pubis and umbilicus, keeping the abdominal peritoneum closed during the surgery. Reperitonealization is done at completion to isolate the urinary anastomoses from the bowel anastomoses. Seventy-six consecutive patients with bladder cancer underwent this operation. The mean operation time was 4 h 30 min and the mean hospital stay was 11 days. No mortality was seen in the early postoperative period. Only one patient developed serious bowel distension. Two patients developed pneumonia. Wound infection was seen in two patients. Two patients experienced hydronephrosis in the late period of follow-up. Four patients developed pelvic lymphocele. There was no evidence of postoperative electrolyte loss in any of the patients. Three patients developed abdominal hernia and this was corrected with surgical treatment. Urodynamic evaluation of 15 patients showed a low capacity reservoir. All patients were continent during the daytime. This technique keeps the abdominal peritoneum closed during radical cystoprostatectomy, preventing the patients from complications, such as infection, water and electrolyte imbalances. The technique also decreases the recovery time.

The Localization of the Infrapatellar Nerves in the Anterior Knee Region With Special Emphasis on Central Third Patellar Tendon Harvest: A Dissection Study on Cadaver and Amputated Specimens

Summary: The aim of this dissection study on cadaver and amputated specimens was to determine the position of the infrapatellar nerves in the anterior knee region, and to investigate whether it would be possible to harvest the patellar tendon through two small vertical incisions, leaving the infrapatellar nerves undamaged and the major part of the paratenon intact. The infrapatellar nerve did not pass through the area between the apex of the patella and the tibial tubercle in 1 of 60 specimens. The nerve passed through this area as one branch in 15 of 60 specimens, as two branches in 37 of 60, as three in 6 of 60, and as four in 1 of 60 specimens. The distance from the apex of the patella to the infrapatellar nerve or the uppermost branch of the nerve was 30 mm (± 27 mm [2 SD]). The distance from the tibial tubercle to the infrapatellar nerve or the lowermost branch of the nerve was 27 mm (± 27 mm [2 SD]). In one specimen, the infrapatellar nerve passed 10 mm distal to the tibial tubercle. In 4 of 60 specimens, a branch of the infrapatellar nerve passed just above the tibial tubercle, and in 2 of 60 a branch passed just above the apex of the patella. In 19 of 20 specimens in which the harvesting procedure was performed, the infrapatellar nerve or the nerve branches were undamaged. The length of the undamaged paratenon was 27 mm (± 23 mm [2 SD]). This study showed that it was possible to harvest consistent bone–patellar tendon–bone autografts through two vertical 25-mm incisions, leaving the infrapatellar nerve undamaged and the paratenon partially intact in the majority of the cadaver and amputated specimens.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 6 (July), 1999: pp 577–586

Fracture-dislocation of the ankle with posterior entrapment of the fibula behind the tibia.

Fracture-dislocation of the ankle with entrapment of the fibula behind the tibia is a rare condition. Prompt recognition and treatment are necessary to prevent permanent disability. In three of four patients, the injury was managed by closed reduction. If the injury is accurately diagnosed and if traction and medial rotation are applied to the foot while the fibular shaft is pushed laterally, a stable, satisfactory reduction may be achieved. If closed reduction fails, a lateral approach through a small vertical incision directly over the fractured fibular malleolus is sufficient to allow open reduction of the fibula.

Left ventriculotomy for closure of muscular ventricular septal defects. Treatment of choice.

Closure of muscular ventricular septal defects (VSDs) through the right atriotomy or right ventriculotomy may be difficult. These VSDs are often located behind the hypertrophied trabeculae carnae or papillary muscle. Residual or recurrent VSD may result from the difficult approach. Between March 1971 and December 1975, we have used the left ventriculotomy near the apex for closure of muscular VSDs in ten children. The patients' ages ranged from five months to eight years and three months. The diagnosis was established by cardiac catheterisation and left ventricular angiocardiogram in all patients. Six patients had multiple VSDs; in four patients VSD in the muscular septum was present (three apical, one midseptal). Operations were performed on cardiopulmonary bypass with moderate hypothermia and intermittent anoxic arrest. VSDs in the membranous septum were closed through the right atrium. Muscular VSDs were approached through a small vertical incision in the left ventricle near the apex. The postoperative course was uneventful in eight patients. Two patients, aged 16 months and eight years, died; histology showed grade IV pulmonary vascular disease in both. All survivors are well four months to five years after the operation, without clinical evidence of residual or recurrent VSD.