Standard Incision Research Articles

What can a lymph node signal? (Our experience of using SLNB for tongue cancer)

Recently, there has been an increase in publications devoted to sentinel lymph node biopsy (SLNB) in oral cancer. It has been established that cervical lymph node involvement, even in small primary tumors, is an unfavorable prognostic sign and is associated with a more than twofold decrease in overall survival. This creates a need to develop new methods for detecting hidden regional metastases, which, in turn, can improve long-term treatment outcomes. Our study included 16 patients with primary tongue cancer cT1-2N0M0 subject to selective or modified radical neck dissection, as well as radical tongue resection. Patients under 18 years of age, with previous neck surgery or radiation therapy, and with iodine allergy were excluded. Sentinel lymph node (SN) mapping was performed using the SPY-PHI Stryker navigation system, which simultaneously displays color video and fluorescence images. Tracers such as ICG (5 mg/mL) and methylene blue (10 mg/mL) were injected around the tumor, followed by a standard neck incision and measurement of fluorescence signal to identify SNs, which were then removed for histologic examination. All patients were able to reconstruct the tongue with local tissues and there were no technique-related complications. Sentinel lymph nodes (SLNs) were successfully identified in all cases, with four patients having histologically confirmed occult metastases. Nodal classification changed in three patients from cN0 to pN1 and one to pN2, and additional blue-staining lymph nodes were found in 11 patients, all of whom remained N0. The ICG sentinel lymph node method has been used in medicine since 1957 to assess organ function and angiography. ICG quickly binds to plasma proteins and is removed by the liver, making it a safe, radiation-free indicator that is less expensive than X-ray methods. The SNB procedure with ICG NIF imaging is simple and fast, but tissue swelling may occur during the first 24 hours. However, detection of nodes through the skin is difficult in patients with normal or high body weight, since the lymphatic vessels are located deeper and are blocked by surrounding tissue. A sentinel lymph node indicates damage to a specific lymphatic channel or collector.

The objective measurement of hypoaesthesia after Total Knee Arthroplasty and its correlation with skin incision length: a prospective study.

This study aims to measure the peri-incisional numbness developing after Total Knee Arthroplasty (TKA) performed using the midline skin incision. It studies the natural course of the numbness and determines its correlation with the skin incision length (SIL). 66 knees undergoing primary TKA with a standard midline incision were evaluated. The SIL and the area of numbness (AON) were measured in complete knee extension and 90° of flexion. The area was marked by the patient using a sketch pen and then determined by an independent observer using monofilament testing. The "ImageJ" software was used to calculate the area. All patients developed numbness around the knee after TKA. There was a statistically significant correlation between the SIL and AON in both flexion and extension at two weeks (p < 0.001) and three months (p < 0.001). However, there was a weak and insignificant correlation at six months (p = 0.217). When TKA is performed using the midline skin incision, the SIL positively correlates with the AON postoperatively during the initial short-term follow-up. At six monthly follow-ups, there is no significant correlation between the two.

Postoperative Horner Syndrome: A Case Report Describing a Rare Complication After Anterior Cervical Discectomy and Fusion

The gold standard for correcting cervical degenerative disc disease (CDDD) is anterior cervical discectomy and fusion (ACDF), which is a safe, effective procedure. Horner syndrome (HS) is an extremely rare complication immediately post-ACDF due to impairment of the sympathetic trunk. Herein, we present the case of a 48-year-old woman with CDDD-related pain and radiculopathy who was counselled and consented for C5–6 and C6–7 ACDF. ACDF was performed with standard anterior left-sided incisions at appropriate levels. Unlike our usual practice, deeper-toothed retractors were employed for better exposure. Two cages were inserted at C5–6 and C6–7. The procedural time was standard (180 minutes), without intraoperative complications. The patient experienced significant symptom relief immediately post-ACDF, but developed sudden onset left-sided HS, with ptosis, miosis, and anhidrosis, approximately 48 hours post-ACDF. At a 2-week postoperative follow-up, she exhibited clinical improvement, and by 12 weeks, her HS had completely resolved. To our knowledge, this case is the first documented instance of delayed-onset HS post-ACDF. It may be associated with the type of retractors used, resulting in neuropraxia or strain on the sympathetic chain ganglia. We recommend adequate exposure while minimizing excessive retraction of the longus colli muscle to reduce irritation to the sympathetic trunk.

A Bicentric, International, Retrospective Study to Assess Steelex Sternum Set for Sternal Closure in Cardiac Surgery – STERCCAS a Cohort Study

Sternal fixation with steel wires or cerclages, is the gold standard for closing a midline sternotomy, the standard incision in cardiac surgery. Rare wound complications can occur following a sternotomy wire closure. The objective of this study is to establish that the clinical efficacy of the Steelex Sternum Set is equivalent to the results documented in existing literature. The cohorts of the previously conducted OPTICABG and PREMIVALVE studies served as a foundation for the design of this retrospective, bicentric, international, single-arm study. The purpose of the study was to evaluate the clinical performance of the Steelex Sternum Set for sternal closure after coronary artery bypass grafting or cardiac valve replacement/reconstruction surgery. The primary endpoint was the incidence of a composite consisting of sternum instability, sternum dehiscence, superficial and deep sternal wound infection up to six months after surgery. A quantitative summary of the available clinical literature has been conducted for comparison purposes. There were 229 patients in total (89 PREMIVALVE and 140 OPTICABG). The combined rate of surgical site infection and sternal dehiscence/instability was 3.49%, compared to 1.5 - 20% described in the literature. Severe complications such as mortality, stroke, myocardial infarction, and mediastinitis occurred in about 0.8 - 2% of cases. The Steelex Sternum Set is a safe and appropriate method for sternal closure in a diverse patient population undergoing cardiac valve replacement and/or reconstruction, as well as coronary artery bypass graft surgery, in routine clinical settings.

Excision of Giant Cervicomediastinal Parathyroid Cyst: Case Report and Literature Review.

While excision for parathyroid cysts remains as the standard of management, surgical approach in the context of massive cervicomediastinal parathyroid cysts can be challenging. We report a rare giant parathyroid cyst in anterior mediastinum successfully resected from a simple standard Kocher's collar incision. Various surgical approach will also be deliberated.

Outcomes of AV fistula formation for dialysis patients using interrupted sutures one-year single center study.

To document the Outcomes of AV fistula formation for dialysis patients using interrupted sutures. In this Cross-sectional study conducted at PNS Shifa Karachi, from June 2022 to June 2023, patients above 18 years of age, male or female, with ESRD/CKD were included. After clinical screening and ultrasound doppler, the distal most part of wrist was considered as a site for radio cephalic AVF. Operation was performed under surgical loupe with 4.5x magnification. Standard incision of about 4-5 cm oblique proximal to the wrist crease was given at the volar surface on the radial side of Distal forearm, extending till the lateral side up to the snuffbox. Subcutaneous tissue was incised and dissection was done to identify the cephalic vein and radial artery. Distal most end of the cephalic vein was ligated using vicryl 4-0 suture and cephalic vein dissected free from the underling tissue to mobilize it up to the radial artery. During the study N=35 patients who required AVF creation visited the department. The mean age of the study participants was 59.34±15.48. If thrill at the site of AVF and backflow at cut end of cephalic vein were present the surgeons were satisfied, higher satisfaction among the surgeon was achieved in the AVF created at brachiocephalic artery while the diameter of vessels didn't contribute in surgeon satisfaction. Presence of thrill at the site of AVF and backflow at cut end of cephalic vein have strong association with good prognosis of AVF.

Moving a skin incision to lateral side of tibial tubercle reduces the risk of persistent skin numbness compared with a regular midline one: A randomized paired study in bilateral total knee arthroplasty

BackgroundThe midline incision during total knee arthroplasty (TKA) is known to damage the infrapatellar branch of the saphenous nerve (IPBSN), leading to lateral flap numbness. The aim was to evaluate the rate of persistent skin numbness (RSN) and area of skin numbness (AON) after a lateral-based skin incision compared with the standard midline incision in bilateral TKA patients. MethodsThirty-six patients undergoing bilateral TKA were included and randomly assigned to receive the lateral skin incision (lateral side of the tibial tubercle) on one knee and the standard midline incision on the contralateral. All other surgical steps were identical. Primary outcomes were the RSN at 1 year and the AON at 6 weeks, 3, 6, and 12 months postoperatively. Kneeling ability test (KAT), operative time, and length of incision were also recorded. ResultsThe lateral incision had half the RSN at 12 months compared to the midline incision (25% vs 53%; p = 0.01). The median AON at 1-year after surgery was 0 [0–0.5] cm2 in lateral incision vs 4 [0–7.5] cm2 in midline group (p < 0.001). KAT was minimally better in the lateral group at 110° of kneeling between 6-month to 1-year. Operative time and length of incision were similar between both groups. ConclusionThe lateral skin incision reduced RSN by approximately 50% compared with the midline incision. The AON in lateral incision was 4 cm2 smaller than midline at 1-year after surgery. Moving a skin incision more lateral may be considered to minimize the numbness after TKA.

Reducing the rate of surgical site infection using iodophor-impregnated adhesive incision draping in spine surgery compared with standard adhesive incision draping: a study in 2279 patients.

While adhesive incision drapes are widely used for reducing surgical site infection (SSI), evidence remains scarce on whether impregnated adhesive incision draping can further reduce the rate of SSI in spine surgery. All patients treated surgically in the authors' high-volume university spine center from January 2018 to December 2021 were retrospectively evaluated and divided into cohorts treated before (the control cohort) and after (the study cohort) introduction of an iodophor-impregnated adhesive incision drape (instead of a standard nonimpregnated adhesive incision drape) at their institute. Epidemiological aspects, baseline characteristics, operative records, and rate and characteristics of postoperative SSI were analyzed and compared between cohorts. Two thousand two hundred seventy-nine consecutively treated patients were included, with an overall SSI rate of 0.5%. Baseline patient findings and surgical characteristics (including indication, localization, procedure, and duration of surgery) did not significantly differ between the 1125 patients in the control cohort and the 1154 patients in the study cohort. Uni- and multivariate analyses showed that use of an iodophor-impregnated adhesive incision drape was the only factor significantly associated with a lower risk of SSI. The SSI rate was significantly lower in the study cohort (0.2% vs 0.8%, p = 0.036). While germs of the skin microbiome such as Staphylococcus epidermidis and S. aureus were predominantly prevalent in both cohorts, fecal germs such as Enterococcus/Enterobacter species were found only in the control cohort and not in the study cohort. The use of iodophor-impregnated adhesive incision drapes in spine surgery can help to lower the rate of postoperative SSI and aid in reducing the risk of fecal germ infections.

Efficacy of modified Park’s technique in the treatment of children with strabismus

Purpose: To investigate the efficacy of modified Park’s technique in children with strabismus.&#x0D; Methods: A total of 120 patients were recruited in the Department of Ophthalmology, Anhui Provincial Children's Hospital, Anhui, China between January 2019 and December 2021. The patients were divided into study and control groups comprising 60 patients each. Control group underwent rectus muscle adjustment suture using standard incision, while study group received modified Park’s technique, which involved intermuscular membrane incision and conjunctiva two-layer suture method. Various parameters such as perioperative indicators, tear film function, and patient satisfaction were assessed.&#x0D; Results: The study group had significantly lower intraoperative blood loss, duration of surgery and length of hospital stay (p &lt; 0.01). Also, it showed significantly higher Schirmer’s time, tear film break-up time (TFBUT) time and significantly lower corneal staining score (p &lt; 0.01). Satisfaction level was significantly higher in the study group compared to control group (p &lt; 0.05). So also was clinical efficacy (91.67 %) compared to control group (83.33 %). Furthermore, study group exhibited significantly lower incidence of complications (5) compared to control group (11; p &lt; 0.05).&#x0D; Conclusion: Enhanced Park’s technique improves perioperative indicators, tear film function, and satisfaction level; it also produces high efficacy and lower incidence of complications. This suggests that it might be a viable substitute for conventional treatment of children with exotropia. However, long-term follow-up data will be required to establish the superiority of this treatment strategy.

Amyand’s Hernia in an Infant: A Case Report and Review of Literature

Introduction: Inguinal hernia is a common surgical disease among a pediatric population with patent processus vaginalis being the major risk factor. Omentum and small intestine loops are the oftenencountered hernia sac contents, however in a rare instance (1% of cases), a vermiform appendix is found in the sac, and it is referred as Amyand’s hernia (AH). The appendix can be normal, inflamed, strangulated, or perforated. Case presentation: 7-week-old male baby with 2-week history of right groin swelling, excessive crying and restlessness. He was clinically stable with irreducible right inguinoscrotal swelling. An ultrasonography confirmed a 1.5 cm abdominal wall defect with bowels in the sac. A clinical diagnosis of incarcerated inguinal hernia was made, and the patient was prepared for surgery. A standard herniotomy incision was done, hernia sac was found and opened and appendix and cecum were found. The contents were reduced, the sac was ligated and transected, and the incision was closed in layers. The post-operative follow ups were uneventful. Discussion: AH is a rare condition, with estimated prevalence of 0.19% to 1.7% and 0.1% occurrence of appendicitis. The clinical presentations of AH include painful groin swelling, inguino-scrotal erythema, tenderness, and features of obstructed or strangulated inguinal hernia. Diagnosis is often made during surgery as it is exceedingly difficult to diagnose it pre-operatively as it resembles inguinal hernia, and it can mimic testicular torsion or inflammation in case of erythema and tenderness. The surgical approach depends on the status of appendix, and it can be reduction of appendix or appendectomy if inflamed. Conclusions: Although rare, an index of suspicion should be kept in all inguinal hernia repairs. The appendix should be preserved if normal as with emergence of novel surgical technologies, the appendix can be of significant use especially for the children.

Corneal epithelial remodeling induced by combined small incision lenticule extraction and accelerated corneal collagen crosslinking for myopia

To evaluate the changes of the corneal epithelial thickness (ET) profile induced by combined small incision lenticule extraction and accelerated corneal collagen crosslinking (SMILE-xtra) for myopia compared with the standard small incision lenticule extraction (SMILE). Nuri Eye Hospital, 61, Dunsan-ro, Seo-gu, Daejeon, 35233, Korea. Retrospective cross-sectional study. Thirty-one myopic eye undergoing SMILE-xtra and control group of 36 myopic eyes undergoing SMILE were retrospectively analyzed. Spectral-domain optical coherence tomography (CIRRUS™ HD-OCT 5000, ZEISS, Dublin, CA) was used to measure corneal ET of 17 zones within the central 7-mm zone at preoperative, postoperative 1 month, 3 months and 6 months. Postoperative ET alterations were analyzed for correlation with treatment parameters. There was no difference in preoperative mean age, postoperative MRSE, visual acuity, and ablation depth between the two groups, and there was a significant difference in preoperative central corneal thickness. Both groups showed the greatest increase in corneal ET in the paracentral area on the inferotemporal area, respectively, for 6 months. The preoperative MRSE and the ablation depth showed significant correlation with the postoperative epithelial thickening in mid-peripheral sectors in both groups, and significant negative correlations in paracentral sectors only in SMILE-xtra group. It is significant as the first study to compare corneal epithelial remodeling between SMILE and SMILE with accelerated corneal collagen crosslinking. The SMILE-xtra with the relatively large corneal ablation did not show a significant difference in the pattern of corneal epithelial remodeling compared to the SMILE group.

COMMA SHAPED INCISION AND ITS INFLUENCE ON POST-OPERATIVE HEALING (PAIN AND TRISMUS) IN COMPARISON WITH STANDARD WARD’S INCISION

INTRODUCTION: The most frequent procedure performed in the oral and maxillofacial surgical department is the surgical extraction of an impacted third molar. A minor surgical intervention with appropriate flap is frequently necessary to remove an impacted third molar. OBJECTIVE: To determine the efficacy of comma shaped incision in comparison with standard ward’s incision among patients with mesioangular mandibular third molar impaction. MATERIAL AND METHODS: This randomized control trial was conducted at Foundation University College of Dentistry Islamabad from 9th October 2015 to 22nd November 2016. Total 116 adult volunteer subjects, 58 in each group within the age range of 18-50 years were assessed. Preoperative radiographs were obtained. Based on the lottery method, the patients were allocated arbitrarily into two equal groups. Ward's incision was given to Group A, and a comma-shaped incision was given to Group B. RESULTS: The patients' mean age (years) was 33.81+5.03. Patients included 97 (83.6%) women and 19 (16.4) men. The effectiveness of the comma-shaped incision compared to the standard ward's incision among patients with mesioangular mandibular third molar impaction in terms of post-operative pain score at 7th day was 35 (60.3) and 21 (36.2), respectively, which was highly significant (p-value 0.009), whereas trismus at 7th post-operative day was 41mm (70.7) and 48mm (82.8), respectively, which was not significant (p-value 0.124) statistically. CONCLUSION: We have concluded from our study that comma-shaped incisions were superior to ward's incisions in terms to lessen discomfort following mandibular third molar surgery, however, trismus in both groups was not effective.

Soft Tissue Structures at Risk With a Percutaneous Focal Dome Osteotomy: A Cadaver Study

The focal dome osteotomy allows deformity correction through frontal plane rotation, and if needed, anterior or posterior translation. This percutaneous technique allows extracapsular ankle realignment with minimal soft tissue dissection. While circumventing a standard anterior incision, this technique encounters soft tissue structures that must be considered. Focal dome osteotomies were simulated on 10 fresh-frozen below the knee cadavers. Centered proximal to the tibial plafond at the physeal scar, a radial arm using a 4-hole Rancho cube was used to map the dome. Medial, lateral, and central incisions were made to allow access for drilling and measured to nearby anatomic structures. Among 10 cadavers, the age and weight were 70 ± 7.96 years and 134.7 ± 30.8 pounds, respectively. In all cadavers, the hole below the most proximal posthole provided the ideal position for the creation of the osteotomy. The medial and central incisions were closest to the tibialis anterior tendon measuring 3.37 ± 2.48 mm and 0.43 ± 0.9 mm, respectively. The lateral incision and half-pin used to create the distal axis of rotation were closest to the extensor hallucis longus tendon, measuring 1.97 ± 1.92 mm and 1.27 ± 1.5 mm, respectively. Drilling the second hole from the top on a 4-hole Rancho cube, forming a 2.50 cm radial arm, created the ideal osteotomy arc. Though neurovascular structures were further away from respective incision and half-pin sites compared to tendons, in several specimens, anatomic variations held them closer, warranting preoperative handheld Doppler and mapping. Care should be taken to protect anterior ankle anatomy during dissection, drilling, and completing the osteotomy.

A new modified limited incision for superficial parotidectomy compared to modified Blair's incision.

Many incisions have been used to perform parotidectomy, but they result in a visible scar on the neck and may cause patient dissatisfaction by producing disfigurement sometimes. The aim of this study is to use a modified limited incision for superficial parotidectomy as an alternative to the classical incision, with no obvious scarring and without affecting the identification of the facial nerve, resulting in better cosmesis. A prospective comparative study on 100 patients has undergone superficial parotidectomy using a modified limited incision and another 100 patients who have undergone superficial parotidectomy using the modified Blair's incision (control group) for variant benign pathologies. The surgeries were conducted in four hospitals (three private and one public) in Baghdad, Iraq, from January 2016 to September 2022. In both groups, the patients were followed up through outpatient visits to assess the cosmetic result of the incision and detect postoperative complications. All tumors were removed with no need for extending the skin incision. The cosmetic result of the incision was very satisfactory and only a nominal scar could be seen 6 months after surgery. Five percent of patients only developed postoperative complications. A modified limited incision for superficial parotidectomy provides better patient satisfaction compared to a modified Blair's incision. The modified limited incision can be performed safely with a better cosmetic appearance of the surgical scar compared to the standard incision.

Long-term survival, cardiovascular, and functional outcomes after minimally invasive coronary artery bypass grafting in 566 patients

ObjectiveSternotomy has been the gold standard incision for surgical revascularization but may be associated with chronic pain and sternal malunion. Minimally invasive coronary artery bypass grafting allows for complete surgical revascularization through a small thoracotomy in selected patients. There is a paucity of long-term data, particularly functional outcomes, for patients who underwent minimally invasive coronary artery bypass grafting. MethodsPatients (N = 566) who underwent minimally invasive coronary artery bypass grafting at a single institution over a 17-year period were prospectively followed. The primary outcome was survival. At late follow-up, patients were contacted for a questionnaire on functional outcomes. Multivariable Cox proportional hazard model identified correlates of the primary outcome. ResultsClinical follow-up was complete for 100% of patients (mean 7.0 ± 4.4 years); a follow-up questionnaire was also completed for 83.9% (N = 427) of live patients. Fifty percent of patients (N = 283) had undergone multivessel grafting. At 12 years, survival for the entire cohort was 82.2% ± 2.6%. On late follow-up questionnaire, 12 patients (2.8%) had greater than Canadian Cardiovascular Score Class II angina and 19 patients (4.5%) had greater than New York Heart Association Class II symptoms. More than 98% of patients did not have pain related to the incision site. Cox proportional hazards analysis identified older age, peripheral vascular disease, prior myocardial infarction, left ventricular dysfunction, cancer in the past 5 years, intraoperative transfusion, and hybrid revascularization as correlates of mortality during follow-up. ConclusionsMinimally invasive coronary artery bypass grafting is a safe and durable alternative to sternotomy coronary artery bypass grafting in selected patients, with excellent short- and long-term outcomes, including for multivessel coronary disease. At long-term follow-up, the proportion of patients with significant symptoms and incisional pain was low.

Biopsies for Soft-Tissue Sarcoma of the Hand: Dangers, Hazards, and Outcomes.

Excisional biopsies for soft-tissue sarcoma (STS) of the hand are commonly done outside of sarcoma centers and can compromise incorporation of the biopsy site into standard limb salvage or amputation flaps. We sought to identify risk factors for these suboptimal biopsies. We analyzed prospective data on all patients (N = 109) who underwent definitive resection of primary STS of the hand between 1995 and 2019 at our institution. Biopsies were classified by type (excisional vs. incisional/needle), whether they were done before referral, and whether the incision could be incorporated into standard limb salvage or amputation flaps (ILS biopsies) or not (NILS biopsies). Analyses examined potential predictors of NILS biopsies and whether outcomes differed by biopsy type. Biopsies done before referral (N = 91) were more likely to be excisional (79% vs. 17%). Excisional biopsies were associated with smaller tumor size (median, 2.0 vs. 3.15 cm; P = 0.025) and longer time to first intervention (1.88 vs. 1.17 months; P = 0.001). Forty-eight percent of excisional and 29% of incisional biopsy sites required soft-tissue coverage at the time of definitive surgery ( P = 0.07). Biopsy type was not associated with Musculoskeletal Tumor Society score or need for amputation. Risk factors for NILS biopsies included larger tumor size, deep tumor, and excisional biopsy. High-risk areas for NILS biopsies included the carpal tunnel, volar wrist, first webspace, radial palm, and proximal thumb. NILS biopsies were associated with positive margins, need for soft-tissue coverage, and lower Musculoskeletal Tumor Society scores. This study informs referral guidelines for patients with STS of the hand. Patients with tumors that are deep, large, or in high-risk locations should be referred to a sarcoma center before biopsy. If that is not possible, incisional biopsy in line with standard resection incisions or radiology-guided core needle biopsy is preferable to excisional biopsy. Prognostic study. Level II.

The Agonist-Antagonist Myoneural Interface in a Transtibial Amputation.

The agonist-antagonist myoneural interface (AMI) technique at the time of transtibial amputation involves the use of agonist-antagonist muscle pairs to restore natural contraction-stretch relationships and to improve proprioceptive feedback when utilizing a prosthetic limb1. Utilizing the standard incision for a long posterior myofasciocutaneous flap, the lateral and medial aspects of the limb are dissected, identifying and preserving the superficial peroneal and saphenous nerve, respectively. The tendons of the tibialis anterior and peroneus longus are transected distally to allow adequate length for the AMI constructs. After ligation of the anterior tibial vessels, the deep peroneal nerve is identified and tagged to create a regenerative peripheral nerve interface (RPNI). The tibia and fibula are cut approximately 15 cm from the medial joint line, facilitating dissection of the deep posterior compartment and ligation of the peroneal and posterior tibial vessels. The tendons of the lateral gastrocnemius and tibialis posterior are transected distally, and the amputation is completed. The extensor retinaculum is harvested from the residual limb along with multiple 2 × 3-cm free muscle grafts, which will be used for the RPNI constructs. The retinaculum is secured to the tibia with suture anchors, and AMI pairs of the lateral gastrocnemius and tibialis anterior as well as the tibialis posterior and peroneus longus are constructed. Separate RPNIs of the major lower-extremity nerves are performed, and the wound is closed in a standard layered fashion. An isometric myodesis of the gastrocnemius without coaptation of agonist-antagonist muscle pairs can be performed at the time of transtibial amputation. The AMI technique restores natural agonist-antagonist relationships at the time of transtibial amputation to increase proprioceptive feedback and improve prosthetic control. These outcomes contrast with those of a traditional isometric myodesis, which prevents proprioceptive communication from the residual limb musculature to the central nervous system. Additionally, the AMI technique allows for concentric and eccentric muscular contractions, which may contribute to the maintenance of limb volume and aid with prosthetic fitting, as opposed to the typical limb atrophy observed following standard transtibial amputation1,2. With the development and availability of more advanced prostheses, the AMI technique offers more precise control and increases the functionality of these innovative devices. Early clinical outcomes of the AMI technique at the time of transtibial amputation have been promising. In a case series of the first 3 patients who underwent the procedure, complications were minor and consisted of 2 episodes of cellulitis and 1 case of delayed wound healing1. Muscle activation measured through electromyography demonstrated an improved ability to limit unintended muscular co-contraction with attempted movement of the phantom limb, as compared with patients who underwent a standard transtibial amputation1. Additionally, residual limb volume was maintained postoperatively without the need for substantial prosthetic modifications. The tendons of the tibialis anterior, peroneus longus, tibialis posterior, and lateral gastrocnemius should be transected as distal as possible to allow adequate length for creation of the AMI constructs.Approximately 2 × 3-cm free muscle grafts are harvested from the amputated extremity for RPNI3.Smooth tendon-gliding through the synovial tunnels should be confirmed before closure. If necessary, muscle debulking can improve gliding and decrease the size of the residual limb.Harvesting the extensor retinaculum for synovial tunnels has been our preferred method, although we acknowledge that other grafts options such as the tarsal tunnel are available1. RPNI = regenerative peripheral nerve interfaceAMI = agonist-antagonist myoneural interfaceEMG = electromyographic.

The Trend of Cholecystectomies After the Introduction of Laparoscopic Surgery in a District Hospital in Abuja, North Central Nigeria.

Background Laparoscopic cholecystectomy is not readily available in secondary care hospitals in Nigeria, even though it is now the gold standard for the treatment of cholelithiasis and other gallbladder diseases worldwide. Thus, many hospitals in Nigeria still offer open cholecystectomies. This retrospective study investigated the trend of cholecystectomies performed in the general surgery unit of a district hospital in Abuja before and after the commencement of laparoscopic surgery services in 2016. Methodology This retrospective study was conducted in Asokoro District Hospital, Abuja, Nigeria The records of all patients who underwent a cholecystectomy from January 2000 to December 2019 were retrieved and analyzed for the number, types, and rate of cholecystectomies performed per year. All open cholecystectomies were performed via a right subcostal incision, whereas all laparoscopic cholecystectomies were performed via the standard four-port incisions approach. Results A total of 96 patients underwent cholecystectomies from January 2000 to December 2019. In total, 50 (52.08%) open cholecystectomies were performed in 20 years with a yearly average of 2.5, and 46 (47.92%) laparoscopic cholecystectomies were performed in four years with a yearly average of 11.5. The trend of open cholecystectomies in four years dropped from three (30%) in 2016 to one (5.26%) in 2019, whereas laparoscopic cholecystectomies increased from seven (70%)to 18 (94.74%) within the same period. Conclusions There is a drop in the trend of open cholecystectomies and an increase in both laparoscopic and total cholecystectomies in our hospital. We recommend adequate capacity and subsidized laparoscopic cholecystectomy for secondary healthcare facilities in Nigeria.

Giant inguinal hernia repair using standard transverse inguinal incision with mesh. A retrospective case control study

BackgroundGiant inguinal hernia (GIH) is a rare condition in the developed world, and the literature is scarce. Case reports describe different techniques in an attempt to prevent abdominal compartment syndrome (ACS). We aimed to review our experience with GIH repair.MethodA retrospective review of the medical records of all consecutive patients who underwent a tension-free mesh GIH repair using a transverse inguinal incision between 2014 and 2021 at a tertiary university referral center. In brief, the technique included head-down positioning, maximal pre-incision reduction of hernia contents, and repair with mesh. Follow-up was conducted in outpatient clinic. We compared the results to a time-based open standard inguinal hernia repair group (control group).ResultsDuring the study period, 58 patients underwent an open GIH repair with mesh without abdominal preparation. 232 patients were included in the control group. The mean surgery duration was 125.5 min in the GIH group and 84 min in the control group (p < 0.001). Bowel resection was not necessary in any case. In-hospital complication rates were 13.8% vs. 5.6% in the GIH and control groups, respectively (p = 0.045). Early complication rates (up to 30 days post-operatively) were 62.1% vs. 14.7% in the GIH and control groups, respectively (p < 0.001). Late complications rate was similar (p = 0.476). ACS and mortality were not reported. No recurrence event was reported in the GIH group.ConclusionTension-free mesh repair for GIH using a standard transverse inguinal incision is feasible and safe and there is no need for abdominal cavity preparation. Early complications are more common than in the control group, but there were no higher rate of late or severe complications and no recurrence event.

Minimally Invasive Distal Biceps Tendon Reconstruction With Semitendinosus Allograft and Dual Unicortical Button Fixation

Complete rupture of the distal biceps tendon is routinely treated with direct repair; however, chronic, mid-substance, or musculotendinous tears are challenging clinical scenarios for surgeons. Although attempts at direct repair should be considered, in cases of severe retraction or tendon deficiency, a reconstruction may be warranted. Herein the authors describe a technique for distal biceps reconstruction using allograft with a Pulvertaft weave via a standard anterior incision, similar to primary repair, with a small catchment incision more proximally for tendon retrieval. Use of this technique with dual unicortical buttons allows for early range of motion, restoration of the distal footprint, and improved biomechanical construct strength, which has proven invaluable in a population of elite and highly active military servicemembers.