Standard Surgical Technique Research Articles

Benefits of vacuum-assisted closure therapy over standard treatments for infected and chronic non-healing wounds after kidney transplantation

Objective: to evaluate the effectiveness of vacuum-assisted closure (VAC) therapy in comparison with standard treatments for infected and chronic non-healing wounds after kidney transplantation.Materials and methods. From June 2018 to November 2019, 75 kidney transplants from deceased donors were performed at the Transplantation Ward of Botkin City Clinical Hospital. There were 47 men (62.6%) and 28 women (37.4%). Standard surgical technique was used. Immunosuppressive therapy was carried out according to a three-component scheme with anti-CD25 monoclonal antibody induction (basiliximab) intraoperatively and on day 4. All patients received antibiotic therapy with protected third-generation cephalosporins for 7 days after surgery. Postoperative complications were evaluated according to the Clavien-Dindo classification. Standard methods, including daily dressings using modern dressing materials (group I) and VAC therapy (group II) were used for treating infected and chronic non-healing wounds.Results. 30-day mortality in the postoperative period was zero. Postoperative complications were recorded in 11 patients (14.6%), of which 7 had postoperative wound complications. Group I included 3 patients (1 with aKlebsiella pneumonia-infected wound and 2 with chronic non-healing wounds and no microflora growth). Group 2 had 4 patients (3 with infected wounds (Esherichia coli- 1,Klebsiella pneumonia- 2) and 1 with chronic non-healing wound). Complete cleansing of wound, absence of bacterial growth according to the microbiological examination, and maturation of granulations according to histological examination were considered as the criteria upon which a wound could be sutured in both groups of patients. The average time between the start of treatment and secondary suturing in group 1 patients was 33.11 ± 5.43 (28-37) and 15.01 ± 3.15 (13-17) days in group 1 and group 2 respectively.Conclusion. VAC therapy in patients with wound complications resulting from kidney transplantation, in comparison with standard treatment, can achieve rapid wound cleansing, acute inflammation relief and accelerated maturation of mature granulation tissue, thereby improving treatment outcomes in this category of patients.

Trends and Usage Patterns of Minimally Invasive Glaucoma Surgery in the United States: IRIS® Registry Analysis 2013–2018

Understanding trends and patterns in the use of minimally invasive glaucoma surgery (MIGS) and patient profiles undergoing each procedure is important given their relative expense and unknown long-term safety and effectiveness. Retrospective analysis. Minimally invasive glaucoma surgeries and standard glaucoma surgeries recorded in the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry. We used the data from IRIS Registry between 2013 and 2018 (inclusive) to measure the annual number of MIGS and standard surgical techniques (trabeculectomy or glaucoma drainage device [GDD] placement) performed in the United States, stratified by demographic characteristics. Secondary analyses of concurrent surgeries and of subsequent surgeries for MIGS and standard surgical technique also were conducted. Trends and sociodemographic characteristics of MIGS use in the United States. Two hundred three thousand three hundred thirty-two eyes and 232 537 unique procedures had associated, documented International Statistical Classification of Diseases and Related Health Problems (ICD), Ninth or Tenth Revision, codes for glaucoma and were included in final analyses. Among eyes with documented glaucoma diagnoses, a substantial increase in annual MIGS procedures occurred over the study period (from 7586 in 2013 to 39 677) and a smaller decrease in standard glaucoma procedures (from 16 215 to 13 701). The proportion of iStent procedures almost tripled during the study period (from 14% to 40%), and by 2017 accounted for almost half (43.7%) of all glaucoma surgeries in the United States. Twenty-one thousand twenty-five of all eyes (10.3%) underwent multiple procedures: 7638 (36.3%) on the same day and 13 387 (63.7%) on subsequent days. Endocyclophotocoagulation and iStent placement were the most common concurrent procedures (55.4% of all concurrent procedures). Trabeculectomy and GDD placement were most commonly followed by another standard glaucoma surgery, but when followed by sequential MIGS, endocyclophotocoagulation and goniotomy were the most common procedures performed (33.0% and 21.9%, respectively). A significant increase in MIGS use occurred over the recent 6-year period, despite limited evidence of their long-term safety or effectiveness, highlighting the need for trials comparing safety and outcomes of novel MIGS versus traditional surgical treatments for glaucoma.

Single-Position Surgery: Prone Lateral Lumbar Interbody Fusion: 2-Dimensional Operative Video.

Lateral lumbar interbody fusion (LLIF) is a widely used technique for anterior fusion. However, posterior decompression or instrumentation often requires repositioning the patient, which increases operative time. This video describes the prone LLIF as a modification of the standard surgical technique. The prone LLIF facilitates simultaneous decompression and fusion, which avoids the need for repositioning the patient, increasing operative efficiency. Positioning, fluoroscopic considerations, and operative nuances involved in performing the LLIF in the prone position are described, and an illustrative case is presented. The patient provided informed consent for the procedure and videography. LLIF in the prone position can decrease operative time and increase operative efficiency. The prone position is a viable alternative to the conventional lateral decubitus position. Video used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Circumcision devices versus standard surgical techniques in adolescent and adult male circumcisions.

Circumcision devices versus standard surgical techniques in adolescent and adult male circumcisions.

Xenografts in the post-operative wound management of interpolation flaps.

Safeguarding the integrity of the donor site during the initial suspension phase of an interpolation flap is difficult. There are a variety of approaches and no consensus on post-operative management of the donor site or pedicle following the creation of the flap. The use of xenografts at the donor site of postauricular interpolation flaps simplifies post-operative wound care and prevents infection, desiccation of tissue, reduces pain, and assists with hemostasis. A porcine acellular dermal skin substitute can be utilized for the purpose of care-free interpolation flap wound care. First, the flap is designed and raised using standard surgical technique. The porcine xenograft is then sutured into the donor site and to the exposed subcutaneous side of the flap pedicle using nylon suture material. The flap then is interpolated and sutured into the surgical defect of the auricle. Silicone gel is applied to the surface of the xenograft. A pressure dressing is then placed over the surgical site. A total of 4 patients had postauricular interpolation flaps to the ipsilateral helix. All four patients had a xenograft placed at the donor site and flap pedicle at the time of the flap creation and suspension. No infections and no incidence of post-operative bleeding requiring intervention were noted. Utilizing a dermal skin substitute as a biological dressing for an interpolation flap prior to division and inset of the flap provides a useful alternative to traditional wound care during this interim period.

Study on Surgical Management of Distal Tibial Fractures by Locking Compression Plates (LCP)

Introduction: Fractures of the distal tibia are one of the most commonly fractures encountered in orthopaedic practice accounting for 7-10% of all tibial fractures. They represent a significant challenge to most of the surgeons. Most common method of management is by internal fixation using locking compression plate. Aim: To evaluate the effectiveness, functional results and complications following internal fixation of distal tibia fractures by locking compression plates (LCP). Materials and methods: In this study, 20 patients of distal tibia fractures treated surgically following internal fixation by LCP plating, studied between January 2019 to March 2020 in department of orthopaedics, Prathima Institute of Medical Sciences, Nagnoor, Karimnagar, and Telangana. All cases treated surgically by LCP plating using standard surgical technique and postoperative protocol. Results: High energy trauma (RTA) accounted for 80% of cases. Surgeries were performed within one week average. Radiological union seen in 16 weeks (range 14-18 weeks) average. weight bearing started from 12 weeks (Range 10- 14weeks). Ankle stiffness noted in 5% of cases. There were 4 cases of superficial infections, 2 patients with deep infection got treated with antibiotics and debridement. Functional results done according to Olerud and molander scoring system. 70% of patients achieved excellent to good results, 30% patients shows fair to poor results. Conclusion: Locking compression plate has better functional outcome, has the advantage of rigid fixation even in osteoporotic fractures and better angular stability.

An intraoperative laterally placed distractor for gradual load sharing correction of severe spastic neuromuscular spinal deformity.

To analyze the overall deformity correction for severe neuromuscular scoliosis using laterally placed intra-operative distraction and compare to those receiving standard surgical technique. This was a retrospective, IRB-approved, cohort study of patients with GMFCS 4 or 5 spastic cerebral palsy with neuromuscular scoliosis, age greater than 10years, who underwent posterior spinal fusion from 2007 to 2019. All patients had vectored cervical traction with Gardner-Wells tongs, with hips flexed in a relative sitting position. The study cohort underwent intraoperative, laterally placed correction using a distractor placed between two upper ribs and the ipsilateral greater trochanter while the control cohort did not. The 24 study patients were compared to 22 control patients. Preoperative comparisons identified significant differences in Cobb angle, preoperative flexibility, and pelvic obliquity with the study group having larger, stiffer deformities with greater obliquity. There were no differences in pre-operative sagittal plane deformity. Mean post-operative upright Cobb angle correction was 67.3° ± 14.8° in the study and 55.3° ± 9.9° in the control group, representing a 66% and 60% correction, respectively. No neurological or other complications were noted from the use of this technique. The use of a laterally placed distraction device from upper ribs to ipsilateral greater trochanter allowed gradual lateral un-bending of large stiff neuromuscular spine deformities with greater correction than that of standard technique. In this small series, the technique allowed load-sharing during correction, with hips remaining in a functional sitting position, and without neurological complications. Level III-retrospective cohort study.

Development of a surgical competency assessment tool for sentinel lymph node dissection by minimally invasive surgery for endometrial cancer

IntroductionSentinel lymph node dissection is widely used in the staging of endometrial cancer. Variation in surgical techniques potentially impacts diagnostic accuracy and oncologic outcomes, and poses barriers to the comparison...

Health-related quality of life and sagittal balance at two to 25 years after posterior transfixation for high-grade dysplastic spondylolisthesis.

AimsHigh-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.MethodsSRS-22r and full-spine lateral radiographs were collected for the 28 young patients (age 13.4 years (SD 2.6) who underwent surgery for high-grade dysplastic spondylolisthesis in our centre (Scottish National Spinal Deformity Service) between 1995 and 2018. The mean follow-up was nine years (2 to 25), and one patient was lost to follow-up. The standard surgical technique was an all-posterior, partial reduction, and S1 to L5 transfixation screw technique without direct decompression. Parameters for segmental (slip percentage, Dubousset’s lumbosacral angle) and regional alignment (pelvic tilt, sacral slope, L5 incidence, lumbar lordosis, and thoracic kyphosis) and global balance (T1 spino-pelvic inclination) were measured. SRS-22r scores were compared between patients with a balanced and unbalanced pelvis at final follow-up.ResultsSRS-22r domain and total scores improved significantly from preoperative to final follow-up, except for the mental health domain that remained the same. Slip percentage improved from 75% (SD 15) to 48% (SD 19) and lumbosacral angle from 70° (SD 11) to 101° (SD 11). Preoperatively, 35% had global imbalance, and at follow-up all were balanced. Preoperatively, 63% had an unbalanced pelvis, and at final follow-up this was 32%. SRS-22r scores were not different in patients with a balanced or unbalanced pelvis. However, postoperative pelvic imbalance as measured by L5 incidence was associated with lower SRS-22r self-image and total scores (p = 0.029).ConclusionIn young patients with HGDS, partial reduction and transfixation improves local lumbosacral alignment, restores pelvic, and global balance and provides satisfactory long-term clinical outcomes. Higher SRS-22r self-image and total scores were observed in the patients that had a balanced pelvis (L5I < 60°) at two to 25 years follow-up.Cite this article: Bone Jt Open 2021;2(3):163–173.

IJU this issue

This issue deals with a wide range of clinical topics of urology, and contains 14 Original Articles. Percutaneous nephrolithotomy (PCNL) is a minimally invasive endourological procedure recommended as first-line therapy for kidney stones >2 cm in diameter. In general, however, nephrectomy is carried out in patients with large stones within non-functioning atrophic kidneys. Su et al. (Beijing, China) evaluated outcomes in patients who underwent total ultrasound-guided PCNL for the management of large stones (>2 cm) within non-functioning atrophic kidneys. Their results showed that ultrasound-guided PCNL is safe and feasible, even for stones >2 cm in diameter within non-functioning atrophic kidneys. However, PCNL is not recommended for patients with diabetes. Several energy sources have been used for stone fragmentation during ureteroscopy. Nowadays, the holmium:YAG laser is a standard method that provides effective and safe disintegration of all stone types. However, it has some disadvantages, such as relatively high retropulsion (which might lead to relocation of the stone into the renal pelvis). Enikeev et al. (Moscow, Russia) estimated the efficacy and safety of SuperPulsed thulium-fiber laser ureteral lithotripsy, and identified optimal laser settings. Their results showed that the SuperPulsed thulium-fiber laser provides effective and safe lithotripsy during ureteroscopy regardless of stone density. Fiber diameter and laser frequency do not influence visibility or safety. Optimal laser settings are 0.5 J × 30 Hz for fragmentation and 0.15 J × 100 Hz for dusting. Subclinical Cushing syndrome is defined as a condition of hypercorticolism in patients with adrenal tumors in the absence of clinical features of Cushing syndrome. Although surgical removal of adrenal tumors for subclinical Cushing syndrome patients has been reported to be beneficial with the improvement of comorbidities, such as hypertension, diabetes mellitus and obesity, the surgical benefit is still controversial. Sato et al. (Chiba, Japan) retrospectively investigated whether the result of the 1-mg dexamethasone suppression test could predict the improvement of comorbidities after adrenalectomy in patients with subclinical Cushing syndrome. Their results showed that the greatest reduction of prescribed drugs is observed in patients whose serum cortisol levels are between 1.8 and 3.0 μg/dL after the 1-mg dexamethasone suppression test, implicating that the 1-mg dexamethasone suppression test can be a useful factor predicting the improvement of comorbidities after adrenalectomy. Today, it is well known that approximately half of cases of infertility are attributable to male factors. Recently, the European Association of Urology guideline for male infertility emphasized that oral anti-oxidants were associated with a significant increase in markers of sperm quality. Among the anti-oxidants, one of the elements perhaps most familiar and well known to the general public is zinc. Tsujimura et al. (Chiba, Japan) tried to clarify the factors associated with semen quality, and confirm whether there was an association between semen quality and serum zinc concentration. Although there was no significant correlation between serum zinc concentration and semen quality, the independent predictors for having values below the World Health Organization criteria for assessing sperm quality in binomial logistic regression analysis were follicle-stimulating hormone and serum zinc concentration. They suggested that semen analysis might be considered in men with a low level of serum zinc and high level of follicle-stimulating hormone when developing a reproductive life plan for fertilization. Yasuda et al. (Tokyo, Japan) developed the gasless approach as another type of minimally invasive endoscopic surgery, and applied it to many kinds of urological surgeries, including partial nephrectomy. In gasless partial nephrectomy, they prioritized clampless and sutureless surgery, if feasible, as an attempt to obtain maximal functional preservation. They investigated the outcomes and feasibilities of gasless laparoendoscopic single-port clampless sutureless partial nephrectomy. Their results showed that clampless and sutureless partial nephrectomy can be safely accomplished in most patients undergoing gasless laparoendoscopic single-port surgery, yielding favorable oncological and functional outcomes. Transurethral resection of the prostate represents the standard surgical technique for the management of benign prostatic hyperplasia with a prostate size <80 mL. However, considerable morbidities are associated with larger sizes. Higazy et al. (Cairo, Egypt) evaluated the safety, efficacy and cost-effectiveness of holmium enucleation of the prostate and bipolar transurethral enucleation of the prostate. Their results showed that both holmium enucleation of the prostate and bipolar enucleation of the prostate are safe and effective in the surgical management of large prostatic adenomas. However, holmium enucleation of the prostate has a shorter operative time and hospital stay, with an earlier catheter removal time, and is more cost-effective than bipolar enucleation of the prostate. None declared.

From open simple to robotic-assisted simple prostatectomy (RASP) for large benign prostate hyperplasia: the time has come.

Robotic-assisted simple prostatectomy (RASP) has recently been studied as an alternative to open simple prostatectomy or endoscopic treatment options. At present, there is no defined recommendation for a robotic procedure as a standard surgical technique to treat large benign prostate hyperplasia. Several robotic techniques have been described since 2007. Contemporaneously, multiple endoscopic enucleation techniques have been proposed. Nevertheless, open simple prostatectomy still remains a mainstay of therapy. We aimed to evaluate the development of robotic-assisted prostatectomy for large benign prostatic obstruction, thus comparing the technical aspects and clinical outcomes with open and endoscopic enucleation. Robotic-assisted simple prostatectomy provides significantly less blood loss and shorter hospital stay but longer operative time compared to open simple prostatectomy. Compared to endoscopic treatments, robotic approaches have a similar perioperative outcome, but cause less urethral trauma or potential bladder neck strictures. Moreover, concomitant bladder pathologies can be treated within the same setting. Robotic-assisted simple prostatectomy is an effective and safe technique, and can hence be considered to become the preferred first-line therapy to treat patients with obstructive large prostate glands.

Five-Year Safety and Satisfaction With the Lightweight Breast Implant.

BackgroundThe B-Lite lightweight breast implant (LWBI) weighs approximately 30% less than traditional silicone implants while maintaining an equivalent size, form, and function. The LWBI thus places less stress on breast tissues and preserves tissue stability and integrity over time, reducing weight-related complications and reoperation rates.ObjectivesThe authors sought to assess the long-term (>5 years) safety and performance of the LWBI in primary and revision augmentation procedures.MethodsA retrospective, single-center, single surgeon analysis of prospectively collected data was performed on 827 consecutive primary and revision augmentation patients operated between December 2013 and January 2019. A total 1653 implants (250-835 cc, mostly round, textured, extra high-profile) were implanted employing standard surgical techniques. Direct physician-to-patient follow-up ranged from 6 to 67 months. Chart data on reoperations and overall complications as well as patient and surgeon satisfaction were analyzed.ResultsThe 5-year per patient Kaplan–Meier reoperation free rate was very high (97.1%). Only 2 of 5 total cases of capsular contracture (CC) grade III required reoperation (Kaplan–Meier rate = 0.2%, CI = 0.1–1.0). No cases of rupture or breast implant-associated anaplastic large cell lymphoma were recorded. A total 94.9% of patients rated the aesthetic outcome, and 95.5% of patients rated the natural look and feel of their breasts at 4 to 5 (satisfied-very satisfied). Similarly, the surgeon rated 4 to 5 on 95.4% of the patients’ aesthetic outcomes.ConclusionsThe favorable safety profile, high patient and surgeon satisfaction, and inherent benefits of reduced weight should make the LWBI a strongly considered strategic alternative to traditional implants.Level of Evidence: 3

Nefrectomía parcial vs enucleación tumoral

Antecedentes y objetivo: La cirugía conservadora de nefronas se ha convertido en la técnica quirúrgica estándar para masas renales de pequeño tamaño, desbancando la tradicional nefrectomía radical. El objetivo del estudio es comparar nefrectomía parcial y enucleación tumoral en función de morbilidad y resultados oncológicos.&#x0D; Material y métodos: Estudio de cohortes retrospectivo de pacientes sometidos a nefrectomía parcial o enucleación en el Hospital Clínico Universitario Lozano Blesa de Zaragoza, entre agosto de 2011 y octubre de 2019. Variables demográficas, clínicas, quirúrgicas y resultados oncológicos han sido analizadas.&#x0D; Resultados: 48 pacientes fueron seguidos 36.1±28.0 meses. Los pacientes sometidos a enucleación tumoral, respecto al grupo de nefrectomía parcial presentaron valores inferiores de sangrado medio (117.7±95.1 ml y 221±293.1 ml, p=0.488), isquemia (46% y 95%, p&lt;0.001), tiempo de isquemia medio (24.6±7.2 min y 25.1±10.4 min, p=0.844) y complicaciones (11.5% y un 22.7%, p=0.442) respectivamente. No se observó recidiva local.&#x0D; Conclusiones: Ambos grupos son comparables en cuanto a estadio tumoral, presentando en el grupo de enucleación un menor sangrado, menor necesidad de clampaje vascular y un tiempo de isquemia similar al grupo de nefrectomía parcial. Ambas técnicas son seguras a nivel oncológico, con una baja tasa de márgenes afectos. Ambas técnicas presentan una baja morbilidad postoperatoria.

Surgical outcomes after collagenase Clostridium histolyticum failure in patients with Peyronie\u2019s disease in a multicenter clinical study

In the present study we aimed to investigate the surgical outcomes of patients with persistent penile curvature (PC) after Collagenase Clostridium histolyticum (CCH) intraplaque injections. Data from 90 patients with persistent PC after CCH in a multicentre study from 6 andrological centres were retrospectively reviewed. Three standardized surgical techniques were performed. Group 1: plaque incision grafting (PIG) with penile prosthesis implant (PPI); Group 2: PIG without PPI; Group 3: Nesbit technique. Hospital stay, operative time, postoperative complications and PC persistency/recurrence (> 20°) were evaluated. Overall satisfaction and functional outcomes were assessed through International Index of Erectile Function-Erectile Function (IIEF-EF), Peyronie’s Disease Questionnaire (PDQ), Female Sexual Function Index (FSFI) administered pre and 3 months postoperatively. Of all, 25 (27.8%) patients received grafting procedure + PPI (Group 1), 18 (20.0%) patients belonged to Group 2, and 47 (52.2%) to Group 3. Bovine pericardium graft and collagen fleece have been used in in 22 (51.2%) and 21 (48.8%) patients, respectively. Median penile length after surgery was 13.0 cm (IQR 12.0–15.0). After surgery, Group 1 showed higher increase in penile length after surgery and better improvements in terms of PDQ-PS. In contrast, both IIEF-EF and FSFI scores did not differ among groups. Overall, 86 (95.6%) did not report any complication. 4 (4.4%) patients had PC recurrence; of those, 2 (8.0%), 1 (5.6%) and 1 (2.1%) cases were observed in Group 1, Group 2 and Group 3, respectively. In case of persistent PC after CCH, surgical correction by grafting with or without concomitant PPI or Nesbit technique emerged as a technically feasible, effective and safe procedure, with no significant postoperative complications.

The Double Life-Saving Approach of Abdominal Radical Trachelectomy during Pregnancy for Early-Stage Cervical Cancer-An Overview of the Literature and Our Institutional Experience.

(1) Background: Cervical cancer is the most common type of cancer encountered during pregnancy, with a frequency of 0.8–1.5 cases per 10,000 births. It is a dire condition endangering patients’ lives and pregnancy outcomes, and jeopardizing their fertility. However, there is a lack of current evidence and consensus regarding a standard surgical technique for pregnant patients who suffer from this condition during pregnancy. The study aims to comprehensively update all published data, evaluating the obstetrical and oncological results of pregnant patients who underwent abdominal radical trachelectomy during early stages of cervical cancer. (2) Methods: A literature search on the Medline, PubMed, and Google Scholar databases was performed, including all articles in question up to July 2020. This study presents an overview of the literature and our institutional experience. (3) Results: A total of 25 cases of abdominal radical trachelectomy were performed during pregnancy for early cervical cancer, including the five cases managed by the authors. Of these, 81% (19 patients) gave birth to live newborns through elective C-section, and 19% (6 patients) experienced miscarriage shortly after the procedure. None of the 25 patients (100%) reported disease recurrence. (4) Conclusions: The results of the current study were satisfactory. However, abdominal radical trachelectomy does not represent the current standard of care for cervical cancer during pregnancy, but it could play an important role if more evidence on its effectiveness will be provided.

Outcome of Proximal Hypospadias Repair in Children using Standard Surgical Technique with Intermediate Vascularised Flap- ARetrospective Cohort Study

Introduction: Hypospadias is a very common congenital anomaly noted in children with reported incidence of 0.4-8.2% in 1000 live birth. Treatment of hypospadias is urethroplasty, but is a difficult procedure due to complex anatomy, nonavailability of adequate tissue for repair, prolonged postoperative course and increased incidence of complications even in experienced hands. Aim: To highlight the complications and functional outcome of various types of proximal hypospadias using standard surgical technique with intermediate vascularised flap. Materials and Methods: This was a retrospective cohort study conducted from on 31 children, between the age of 2-13 years from June 2020 to August 2020. The children had proximal hypospadias with or without chordee were operated using primary procedure Tubularised Incised Plate (TIP) and staged procedure with cover of intermediate vascularised flap. These children had peno-scrotal, proximal, mid and distal penile hypospadias with meatus placed 1.5 cm proximal from the glans tip. In all cases, an intermediate layer of vascularised flap was put to cover the neourethra. Tunica vaginalis flap was used in 27 cases and dartos flap in 4 cases. The outcomes of surgical procedure, early and late complications with follow-up results were analysed using descriptive statistics of frequency and percentage. Final functional results of the procedures and cosmesis were observed during a two-year follow-up period. Results: Out of the 31 patients, 27 patients had urethroplasty (20 staged procedures and seven TIP) with tunica vaginalis as intermediate layer. Another four patients had TIP urethroplasty with dartos as intermediate layer. Four patients of tunica vaginalis as intermediate layer had early urethrocutaneous fistula (14.8%), one patient (3.7%) required closure of fistula and another three closed spontaneously. Two patients had meatal stenosis (7.4%) and four had slight pulled up ipsilateral testis (14.8%). One patient of TIP urethroplasty with dartos as intermediate layer was reoperated for late urethrocutaneos fistula at corona glandis (25%). Conclusion: The outcome of pediatric urethroplasty was favourable with routine use of intermediate vascularised flap in proximal hypospadias repair.

Donor Biliary Anatomy: Not a Determinant of Biliary Complications after Right Lobe Living Donor Liver Transplantation

Background: Donor biliary anatomy may contribute to postoperative biliary complications in donors and recipients following right lobe living-donor liver transplantation (RL-LDLT). Methods: Retrospective analysis of medical records of 1105 consecutive (12/ 2011 - 06/2019) donors and recipients who underwent RL-LDLT at our center. The donors and recipients were divided into 2 groups (with and without postoperative biliary complications) and were compared. The primary endpoints were donor biliary anatomy type and postoperative biliary complication incidence; the secondary endpoints were 1-, 3- and 5-year graft and patient survival rates. Results: Based on intraoperative cholangiogram among donors, 855 (77.3%) had type A, 141 (12.8%) had type B, 71 (6.4%) had type C, 25 (2.2%) had type D, and 13 (1.2%) had type E biliary anatomy. Biliary complications occurred in 37 donors (3.3%): bile leakage in 33, intraoperative bile duct injury in 2, and biliary stricture in 2. The most common reason for biliary complications among donors was missed caudate duct(s). Seventy-four (6.7%) recipients developed biliary complications: 20 had bile leak, 43 had biliary stricture, and 11 developed blie leak + stricture. Sarcopenia was the only significant factor for biliary complications in recipients. None of the donor had long-term sequelae. Recipients with biliary complications had inferior graft and patient survival. Conclusions: The incidence of biliary complications in donors or recipients after RLDLT was not related to donor biliary anatomy type. With standardized surgical technique, biliary complications can be minimized and donor biliary anatomy should not be considered a contraindication to right lobe liver donation.

Robotic Roux-en-Y gastric bypass: surgical technique and short-term experience from 329 cases.

minimally invasive bariatric surgery is clearly superior over open procedures including better early outcomes. Different surgical approaches are used to treat the severely obese, having Roux-en-Y gastric bypass (RYGB) being a highly frequent procedure. Robotic surgery overcomes some laparoscopic limitations adding ergonomics, articulating instruments and a three-dimensional high definition camera. Based on our vast robotic experience, we present our referred group case series and a standardized Robotic Roux-en-Y gastric bypass (rRYGB) technique as well as its outcomes. a review of a prospective maintained database was conducted in patients submitted to robotic Roux en Y bariatric surgery between April 2015 and July 2019. Surgical technique is described and illustrated. We also reported patients demographics, outcomes and its follow-up. a Retrospective analysis identified 329 patients submitted to Robotic Roux-en-Y gastric bypass. Both da Vinci Si and Xi platforms were used. Mean age was 34.4 years, with median BMI of 44.2 kg/m2. Mean console time was 102 min and there was no conversion. No surgical hospital readmission rates were seen in the first 30 days. this study represents our initial experience of robotic Roux-en-Y gastric bypass (rRYGB), its short outcomes and a standardized surgical technique. Our results encourage that rRYGB is technically feasible and safe, and might offer some advantages showing good outcomes and minimal complications.

Gentamicin pre-soaking of hamstring autografts decreases infection rates in anterior cruciate ligament reconstruction.

AimsGraft infection following anterior cruciate ligament reconstruction (ACLR) may lead to septic arthritis requiring multiple irrigation and debridement procedures, staged revision operations, and prolonged courses of antibiotics. To our knowledge, there are no previous studies reporting on how gentamicin pre-soaking of hamstring grafts influences infection rates following ACLR. We set out to examine this in our study accordingly.MethodsThis retrospective study included 2,000 patients (1,156 males and 844 females) who underwent primary ACLR with hamstring autografts between 2007 to 2017. This included 1,063 patients who received pre-soaked saline hamstring grafts for ACLR followed by 937 patients who received pre-soaked gentamicin hamstring grafts for ACLR. All operative procedures were completed by a single surgeon using a standardized surgical technique. Medical notes were reviewed and data relating to the following outcomes recorded: postoperative infection, clinical progress, causative organisms, management received, and outcomes.ResultsSuperficial wound infection developed in 14 patients (1.31 %) receiving pre-saline soaked hamstring grafts compared to 13 patients (1.38 %) receiving pre-gentamicin soaked hamstring grafts, and this finding was not statistically significant (p = 0.692). All superficial wound infections were treated with oral antibiotics with no further complications. There were no recorded cases of septic arthritis in patients receiving pre-gentamicin soaked grafts compared to nine patients (0.85%) receiving pre-saline soaked grafts, which was statistically significant (p = 0.004).ConclusionPre-soaking hamstring autographs in gentamicin does not affect superficial infection rates but does reduce deep intra-articular infection rates compared to pre-soaking hamstring grafts in saline alone. These findings suggest that pre-soaking hamstring autografts in gentamicin provides an effective surgical technique for reducing intra-articular infection rates following ACLR.Cite this article: Bone Jt Open 2021;2(1):66–71.

New Anesthetic Technique for Dacryocystorhinostomy: 218 Cases with Local-Anesthesia Ultrasonographic Guided and Blunt Cannula

Introduction: Epiphora is a common ophthalmologic complaint and referrals to oculoplastics and, in the presence of lower complete lacrimonasal duct obstruction, may lead to mild to severe complications, thus requiring surgery to create a new drainage path. The external dacryocystorhinostomy with silicon intubation is the surgical technique with better long-term outcomes and performed in the institutions where this study was conducted. Can be performed under either general or loco-regional anesthesia, or a combination of both. Methods: This article presents a revision of 218 consecutive cases from December 2016 to June 2021 in two specialized centers with the same standardized surgical and anesthetic technique. Results: 242 surgical prontuaries were selected, with 218 filling the inclusion criteria. 13% of the patients required additional anesthetic infusion before the beginning of the surgery; 2.7% of the patients required field anesthetic infusion during the surgery and 6.4% required supplementary sedation, thus meaning a positive outcome, as the number of patients with intraoperative complaints was low, and the overall comfort was high. During the follow up, no patient required pain medication after 24 hours. Discussion: This study points towards the feasibility of the described technique in an outpatient fashion, with low, mild and tolerable side effects associated.