Surgeon Preference Research Articles

Closing-Wedge and Opening-Wedge High Tibial Osteotomy as Successful Treatments of ‎Symptomatic Medial Osteoarthritis of the Knee: A Randomized Controlled Trial.

Closing-wedge high tibial osteotomy (CWHTO) and opening-wedge high tibial osteotomy (OWHTO) are commonly used osteotomy techniques for the symptomatic knee osteoarthritis treatment. However, there is no consensus on which method provides superior outcomes. In this study, we compared the clinical outcomes, radiologic outcomes, and postoperative complications of these techniques. In a randomized controlled trial, 76 patients with medial compartment knee osteoarthritis and associated varus ‎malalignment were randomized into the CWHTO and OWHTO groups (n=38). The primary outcome measures were knee function evaluated by Knee Injury and Osteoarthritis Outcome Score (KOOS) and knee pain assessed by a visual analog scale. The secondary outcome measures were posterior tibial slope (PTS), tibial bone varus angle, and postoperative complications. Both techniques significantly improved the clinical and radiologic outcome measures. The mean improvement of total KOOS was not significantly different between the CWHTO and OPHTO groups (P=0.55). Moreover, the improvement in various KOOS subscales was not significantly different between the two groups. The mean improvement of Visual Analogue Scale (VAS) was not significantly different between the CWHTO and OWHTO groups (P=0.89). The mean PTS change was not significantly different between the two groups (P=0.34). The mean improvement of the varus angle was not significantly different between the two groups (P=0.28). The rate of postoperative complications was not remarkably different between the CWHTO and OWHTO groups. Considering no observed superiority of each osteotomy technique over the other one, ‎two ‎techniques could be used interchangeably and based on the surgeon's‏ preference.

Access, Safety, and Barriers in Adoption of Emergency Laparoscopy Surgery for Trauma Patients in a Low-Resource Setting.

Introduction This study analyzes barriers to the adoption of emergency laparoscopy (EL), safety, and accessibility in a low-resource setting of a low- and middle-income country (LMIC). Methods In this prospective observational study, patients with blunt trauma abdomen (BTA) who required exploration were included and divided into two groups-open exploration (open surgery [OSx]) and laparoscopic exploration (laparoscopic surgery [LSx]). Data were compiled and analyzed. Results Out of 94 BTA patients, 66 required exploration, and the rest were managed conservatively. Out of 66 patients, 42 were in OSx and 24 were in LSx, reason for not selecting LSx was the surgeon's preference for OSx in 26 patients and the lack of availability of operation theater (OT) slots in 16 patients. LSx even after indication was less likely if patients had preoperative evidence of perforation peritonitis. Conclusion Lack of resources (OT availability and trained personnel) are barriers to the adoption of emergency LSx in low-resource settings.

A comparison of two surgical methods in the treatment of shoulder adhesive capsulitis.

The purpose of the study was to compare the outcomes of arthroscopic capsular release surgery and manipulation of patients with resistant primary adhesive capsulitis (AC) under anesthesia. The study comprised forty-four patients who had surgery after being given a diagnosis of primary AC. Patients who had both passive and active glenohumeral and scapulothoracic movements equal to or less than 100° elevation and less than 50% of external rotation compared to the contralateral side were considered to have resistant adhesive capsulitis and were included in the study. Conservative treatments such as intra-articular steroid injections and physical therapy had failed to relieve the pain in these patients for at least six months. The patients who took part in the trial underwent manipulation under anesthesia (group 1) and arthroscopic capsular release (group 2) operations. The chosen surgical procedure was chosen at random and based on the surgeon's preferences. examining the patients' demographic information. After treatment, the patients were examined at three-month, six-month, and one-year intervals. Joint range of motion, visual analogue scale (VAS), and Constant-Murley shoulder scores were all recorded. Statistics were used to compare the outcomes of the two surgical techniques in this study both before and after the procedure. The study's participants' gender, side, extra procedure, and age factors did not show a statistically significant difference between groups 1 and 2 (p<0.05). According to the age, gender, side, additional process, and homogeneous distribution throughout the groups. No statistically significant difference was discovered between groups 1 and 2 in any of the measurements taken from study participants during the follow-up period: Pre-op visual pain scores (VPS), Post-op 3rd month VPS, Post-op 1st year VPS, Pre-op Constant score, Post-op 6th month Constant score, and Post-op 1st year Constant score (p<0.05). The change in VPS and Constant Score values over time did not show a statistically significant difference between the groups (p<0.05). A statistically significant difference between the groups was discovered in each of the Pre-op period and Post-op 6th month VPS assessments (p<0.05). Although there was no statistically significant difference between the two studied therapies, the surgical method was shown to be more beneficial in both groups the shorter the pre-op period was between the onset of the complaints and the operation.

Comparison of supratentorial meningioma resection outcomes by dural reconstruction technique.

Excision of intracranial meningiomas often requires resection or coagulation of the dura mater. The choice of dural closure technique is individualized and based on surgeon preference. The objective of this study was to determine outcomes following various dural closure techniques for supratentorial meningiomas. A retrospective, single-center cohort study was performed for patients who underwent excision of supratentorial meningiomas from 2000 to 2019. Outcomes including operative time, postoperative in-hospital complications, readmission, causes of readmission including surgical site infection, pseudomeningocele, need for shunt surgery, and imaging appearance of pseudomeningocele on long-term follow-up imaging were compared. Univariate and multivariable analyses were conducted. A total of 353 patients who had complete clinical and operative data available for review were included. Of these patients, 227 (64.3%) had nonsutured dural graft reconstruction and 126 (35.7%) had sutured dural repair, including primary closure, artificial dura, or pericranial graft. There was significant variability in using nonsutured dural reconstruction compared with sutured dural repair technique among surgeons (p < 0.001). Tumors with sagittal sinus involvement were more likely to undergo nonsutured closure (n = 79, 34.8%) than dural repair (n = 26, 20.6%) (p = 0.003). There were no other differences in preoperative imaging findings or WHO grade. Frequency of surgical site infection and pseudomeningocele, need for shunt surgery, and recurrence were similar between those undergoing nonsutured and those undergoing sutured dural repair. The mean operative time for the study cohort was 234.9 (SD 106.6) minutes. The nonsutured dural reconstruction group had a significantly shorter mean operative time (223.9 [SD 99.7] minutes) than the sutured dural repair group (254.5 [SD 115.8] minutes) (p = 0.015). In a multivariable linear regression analysis, after controlling for tumor size and sinus involvement, nonsutured dural graft reconstruction was associated with a 36.8-minute reduction (95% CI -60.3 to -13.2 minutes; p = 0.002) in operative time. Dural reconstruction using a nonsutured graft and sutured dural repair exhibit similar postoperative outcomes for patients undergoing resection for supratentorial meningiomas. Although sutured grafts may sometimes be necessary, nonsutured graft reconstruction for most supratentorial meningioma resections may suffice. The decreased operative time associated with nonsutured grafts may ultimately result in cost savings. These findings should be taken into consideration when selecting a dural reconstruction technique for supratentorial meningioma.

Comparison of Postoperative Outcomes of Laparoscopic Cholecystectomy with or without Abdominal Prophylactic Drainage: A Prospective Interventional Study

Introduction: With increasing surgeon experience and advancements in instrumentation and equipment, Laparoscopic Cholecystectomy (LC) continues to progress as a safer and less invasive procedure. Drainage should not be regarded as obligatory or standard after elective LC, according to the majority. Aim: To evaluate the efficacy of elective LC with and without abdominal drainage and to compare the postoperative outcomes among the groups. Materials and Methods: This prospective interventional study was carried out among all patients admitted for elective LC at the Department of Surgery, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India from October 2022 to July 2023. A total of 200 patients scheduled for LC were divided into a drain group (n=92) or a no-drain group (n=108). Allocation was non randomised and based on surgeon preference. Along with demographics, surgical details including operation time, estimated blood loss, time to first flatus and tolerance of water and solid nutrition, postoperative hospital stay duration, and postoperative complications were noted and compared. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) software (SPSS Inc., Chicago, IL, USA) for the Windows program (version 26.0). The continuous and dichotomous variables were evaluated using student’s t-test and Chi-square test. Results: The mean age of patients in the drain and no-drain groups was 57.18±14.39 years and 55.61±14.83 years, respectively, with a female predominance. The no-drain group had a significantly shorter mean operation time than the drain group (93.27±30.81 min vs 124.86±38.64 min). Hospital stays in the no-drain group were substantially shorter (5.47±2.61 days) than those in the drain group (7.56±3.91 days). The postoperative morbidity rates were 14 (15.22%) in the drain group and 10 (9.26%) in the no-drain group. There was no significant difference between the groups in terms of postoperative complications. During the study, no patients in either group required reoperation. The most frequently cited reasons for drain placement were intraoperative haemorrhage (n=11) and difficult operation (n=11). Conclusion: The use of drains after simple, elective, uncomplicated LC could be safely restricted to patients deemed appropriate by the surgeon. Regarding postoperative complications, the no-drain group is superior in its use.

Surgeon Preference not better than Random Selection in choosing between Decompression or Fusion in Degenerative Spondylolisthesis – a Survey alongside a Randomised Trial

Surgeon Preference not better than Random Selection in choosing between Decompression or Fusion in Degenerative Spondylolisthesis – a Survey alongside a Randomised Trial

Esthetic preferences of orthodontists, dentists, and plastic surgeons for balanced facial profiles.

The aim of this investigation was to determine whether the facial esthetics of subjects rated as "attractive" can be related to specific cephalometric soft tissue parameters. The profile silhouettes of 100 subjects (45 males and 55 females) were rated by 60 esthetics specialists (20 orthodontists, 20 dentists, and 20 plastic surgeons) using a Likert scale, and 30 of the subjects were selected as being "attractive". The cephalometric measurements of the attractive group were then compared with norms for the general Caucasian population. The effects of specific measured parameters on profile beauty grades were assessed using the median test, and the following variables were found to show significant correlations between the Caucasian norms and the attractive profile group: the ratio of the upper to lower face height (P = 0.011), the ratio of the subnasale - labrale inferius (Sn-Li) and labrale inferius - menton (Li-Me`) lines (P = 0.011), the distance between the chin and the subnasale perpendicular (P = 0.002), upper lip thickness (P = 0.021), soft tissue chin thickness (P = 0.021), vertical height ratio (P = 0.021), and nasolabial angle (P = 0.021). A straight profile with a fuller and more protruded upper lip, a higher nasal tip, and a smaller lower facial third are considered to be the most attractive facial features, and may be useful for improvement of facial esthetics.

TRACHEOSTOMY: REVIEW OF LITERATURE

Tracheotomy is a surgical procedure in which a tracheocutaneous airway is created in the anterior neck. It is routinely done in critically ill patients requiring prolonged mechanical ventilatory support or in emergency cases of upper airways obstruction. Both open surgical tracheostomy and percutaneous dilatational tracheostomy are methods used to perform tracheostomy in select individuals. The best technique for performing tracheostomy remains a matter of debate. Each method has his advantages and disadvantages. The determining factors in deciding whether to use an open surgical or percutaneous dilatational tracheostomy in a particular situation depends on patient anatomical and physiological factors and as well on surgeon experiences and prefers. The basic technique and variations are described.

Outcomes of Open Appendicectomy by Simple Ligation versus Invagination in Acute Appendicitis- A Prospective Observational Study

Introduction: Surgical techniques in open appendicectomy has been evolving with most centers following simple ligation of appendix stump as the most preferred approach including the laparoscopic approach. Invagination of stump of the appendix is also practiced as a traditional approach. Aim: To compare and evaluate the outcomes and postoperative morbidity of simple ligation and invagination appendicectomy techniques. Materials and Methods: This was a prospective observational study conducted from October 2016 to July 2018 and included a total of 100 patients of acute appendicitis undergoing emergency open appendectomy surgery. The method of surgery of simple ligation and invagination appendectomy was allotted alternatively with 50 patients in each category. Both techniques of surgery were compared in terms of operating time, duration of hospital stay and postsurgical complications. Relevant data was collected and entered in Microsoft excel and p-value was calculated using Chi-square test. Results: A total of 100 patients were included with a mean age of 27 years. Both the groups with 50 patients each, were equivalent with age and gender distribution. It was observed that both the techniques had similar outcomes in respect to mean duration of surgery, duration of hospital stay and morbidities (p-value&gt;0.05) with no statistically significant difference. The morbidity and the rate of postoperative complications were similar in both the groups. Conclusion: Appendicular stump management after appendectomy can be treated either by simple ligation or by invagination method, both techniques being equally effective and safe. Hence, it is surgeons preference to choose among the two techniques.

General Population and Surgeon Preferences for Pollicization Versus Toe-To-Thumb Transfer for Reconstruction of Traumatic Thumb Loss in Adults: An International, Multi-Center Survey Study

Data objectively comparing outcomes following pollicization versus toe-to-thumb transfer for reconstruction after traumatic thumb amputation in adults remains sparse. Given that this decision is reliant on personal preference, it is important to understand the subjective nature of these preferences, particularly in the context of culture. The purpose of this study was to compare Eastern and Western societal and hand surgeon preferences for pollicization versus toe-to-thumb transfer for traumatic thumb reconstruction. Investigators from 6 international locations recruited local hand surgeons and members of the general population. Austria, Germany, the United States, and Spain were grouped as "Western" nations. China and India separately represented "Eastern" nations. Participants completed a questionnaire evaluating their personal preferences for pollicization and toe-to-thumb transfer. The questions posed to the general population and hand surgeons were identical. Demographic data were also collected. When comparing the Western nations, China, and India, there was no difference in personal preferences within the general population for pollicization versus toe-to-thumb transfer. In contrast, most Indian hand surgeons favored toe-to-thumb transfer and most Western surgeons were uncertain about which procedure they would favor. Surgeons had more optimistic expectations regarding postoperative hand function, new thumb sensation, and hand appearance following pollicization than the general population. Similarly, for toe-to-thumb transfer, a greater proportion of surgeons predicted good-to-excellent function, sensation, and appearance. There was no clear, observed "East" versus "West" difference in the general population's personal preferences for pollicization versus toe-to-thumb transfer among study participants. The members of the general population and hand surgeons had different outcome expectations. Understanding how culture influences patient and hand surgeon preferences for pollicization versus toe-to-thumb transfer may help guide future decision-making for traumatic thumb reconstruction.

Surgical Methods of Management for Hidradenitis Suppurativa: A Narrative Review

Objective Hidradenitis Suppuravita (HS) is a chronic condition that creates a significant burden on a patient’s life, both physical and emotional. While a broad range of medical and dressing treatments exist for HS, surgery is often considered the only curative approach. The aim of this study is to comprehensively review existing and emerging surgical options available for the treatment of HS. Methods Using the key phrase “Hidradenitis Suppuravita” and the MeSH terms “surgery or surgical” and “treatment or procedure”, a search of the Ovid Medline and Pubmed databases was conducted 2012 to 2022. Forty-eight studies meeting criteria were identified and included in the literature review. Results Many methods exist for the treatment of HS and there have been promising small scale series and reports that highlight positive disease and quality-of-life (QoL) outcomes associated with some surgical treatment modalities. Most methods are centred around excision of all diseased tissue followed by varying methods of reconstruction. Some novel methods, such as laser ablation, are also used. Each method has its own strengths and weaknesses. Selection of method is currently made based on a case-by-case basis such as disease severity, disease location and surgeon preference. Conclusion Further randomised control trials with larger patient populations are needed to quantify the efficacy and safety of the various surgical methods available. These approaches to treatment hold tremendous potential for improving patient outcomes globally.

Full versus Baby Dose Aspirin for Antithrombotic Prophylaxis in Free Tissue Transfer: Does Size Matter?

All patients undergoing free tissue transfer of the extremities from 2008 to 2020 were retrospectively reviewed. They were divided into two groups based on the postoperative dose of aspirin administered (full versus baby dose). The decision to administer full or baby dose was based on the surgeon's preference. Primary outcome was revision of the arterial anastomosis. Secondary outcomes included flap complications. A total of 183 patients were identified. Out of those, 78 patients received full dose aspirin postoperatively, whereas 105 received a baby dose of aspirin. Patients who received baby aspirin did not have a higher incidence of returning to the operating room for revision of their arterial anastomosis [7.6% versus 7.7%; adjusted odds ratio, 0.93 (95% confidence interval, 0.28-3.11); adjusted P, 0.906]. No differences were found between the two groups in complete and partial flap loss, wound dehiscence, or infection. None of the patients experienced any aspirin-related gastrointestinal complications. In patients undergoing free tissue transfer, thrombosis of the arterial anastomosis is rare. Administration of a full dose of aspirin postoperatively was not superior to a baby dose of aspirin in preventing arterial-related complications.

Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%). The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Association between appendiceal stump closure method and post-operative bowel obstruction after laparoscopic appendectomy

BackgroundLaparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database. MethodsWe queried the Pediatric Health Information System (PHIS) for patients ages 3–18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 – 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation. ResultsIn total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8–14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 – 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 – 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis. ConclusionSBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method. Level of evidenceLevel III. Study typeRetrospective Comparative Study.

The short and long-term effects of open vs minimally invasive thymectomy in myasthenia gravis patients: a systematic review and meta-analysis.

Thymectomy has been utilized as a treatment for Myasthenia Gravis (MG) for many decades, with both open and minimally invasive surgical (MIS) techniques currently used. Although MIS has shown improved short-term results, long-term effects remain uncertain. This systematic review and meta-analysis aim to compare the post-operative and long-term outcomes of MIS versus open thymectomy in MG patients. MEDLINE, EMBASE and CENTRAL databases were searched from inception till January 2022 for keywords related to MG and open or MIS thymectomy. Primary outcome was complete stable remission (CSR), and secondary outcomes were clinical improvement, complications, length of stay, operation time, and blood loss. Grading of recommendations, assessment, development, and evaluation was used to assess the certainty of evidence. 26 studies with 3588 patients were included in the analysis. At 1, 3 and 5years, there was no statistical difference noted in CSR between open versus MIS thymectomy. However, CSR was improved at 1year for MIS thymectomy in non-thymomatous MG (P = 0.03). There was no significant difference in rates of partial clinical improvement between techniques at 1-year. Although analyses on length of hospital stay and blood loss showed improvement following MIS thymectomy, operative time was shorter for open thymectomy. This is the first systematic review and meta-analysis assessing long-term effects of MIS versus open thymectomy in MG patients. Given the lack of significant differences noted, either MIS or open thymectomy can be performed, based on surgeon preference. Further high-level, long-term research should be conducted to determine the benefit of each technique.

Isthmic retroperitoneal cerclage via vNOTES as a potential alternative to an abdominal cerclage: First technique description.

ObjectiveTo describe a new technique for performing an isthmic retroperitoneal cerclage via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). DesignStepwise explanation of the surgical technique using original video footage. This study was exempted from requiring hospital IRB. SettingDepartment of Obstetrics and Gynaecology, Imelda Hospital, Belgium. InterventionA circumferential vaginal incision is made around the cervix after infiltration of the tissue with local anaesthetic and adrenaline. The bladder is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. The rectum is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. A Gelpoint vPath (9.5 cm) (Applied Medical, Rancho Santa Margarita) is used as a vNOTES port. The inner ring of the Alexis is inserted into the retroperitoneal dissection space around the cervix, covering the bladder anteriorly and the rectum posteriorly. An insufflation stabilization bag (ISB) is connected to the Gelseal cap to minimize pressure fluctuations within the confines of the retroperitoneal operative space. The paracervical space is opened just inferior to the uterine artery. A paracervical tunnel is made from the anterior to the posterior retroperitoneal space just lateral to the cervix and just inferior to the uterine artery. This procedure is performed bilaterally. A vessel loop is inserted from anterior to posterior through the paracervical tunnel on each side of the cervix. The Gelseal cap is removed and an Ethibond-2 suture is tied to the vessel loop. The Gelseal cap is placed again. By pulling on the vessel loop, it is replaced by the Ethibond suture. The Ethibond suture is now tied endoscopically to complete the cerclage; alternatively the suture could be tied vaginally without endoscopic instruments to the surgeon's preference. The vNOTES port is removed and the vaginal mucosa is sutured to the cervix again using a resorbable suture. DiscussionAbdominal cerclage is the preferred approach to treat patients with refractory cervical insufficiency [1]. Over the last 20 years this technique increasingly gets performed laparoscopically with similar success rates [2]. The new transvaginal approach demonstrated in this video article may help reduce the invasivess even more by avoiding abdominal incisions and opening the peritoneum, while still benefiting from the vNOTES endoscopic visualization and minimally invasive instruments [3]. The cerclage is placed permanently at the level of the isthmus, similar to an abdominal cerclage. It is placed more cranially than a McDonald or Shirodkar cerclage and leaves no non-resorbable sutures in the vagina [4]. It can be an alternative to a conventional transvaginal cervicoisthmic cerclage [5,6] in patients with a narrow vagina and without uterine descensus. Following the guidelines of the IDEAL collaboration we present this technique to be peer reviewed in its early developmental phase before starting further studies [7]. ConclusionThis is a first feasibility and technique description report on performing a retroperitoneal isthmic cervical via vNOTES. This technique should be considered new, not to be performed on pregnant patients or outside of clinical trials, and only in carefully counselled patients.

Intraoperative Ergonomic Assessment of Exoscopes versus Conventional DIEP Flap.

This study compared the ergonomics of surgeons during deep inferior epigastric perforator (DIEP) flap surgery using either baseline equipment (loupes, headlights, and an operating microscope) or an exoscope. Plastic surgeons may be at high risk of musculoskeletal problems. Recent studies indicate that adopting an exoscope may significantly improve surgeon postures and ergonomics. Postural exposures, using inertial measurement units at the neck, torso, and shoulders, were calculated in addition to the surgeons' subjective physical and cognitive workload. An ergonomic risk score on a scale of 1 (lowest) to 4 (highest) was calculated for each of the postures observed. Data from 23 bilateral DIEP flap surgeries (10 baseline and 13 exoscope) were collected. The neck and torso risk scores decreased significantly during abdominal flap harvest and chest dissection, while right shoulder risk scores increased during the abdominal flap harvest for exoscope DIEP flap procedures compared with. Exoscope anastomoses demonstrated higher neck, right shoulder, and left shoulder risk scores. The results from the survey for the "surgeon at abdomen" showed that the usage of exoscopes was associated with decreased performance and increased mental demand, temporal demand, and effort. However, the results from the "surgeon at chest" showed that the usage of exoscopes was associated with lower physical demand and fatigue, potentially due to differences in surgeon preference. Our study revealed some objective evidence for the ergonomic benefits of exoscope; however, this is dependent on the tasks the surgeon is performing. Additionally, personal preferences may be an important factor to be considered in the ergonomic evaluation of the exoscope.

Supraorbital transciliary approach as primary route to fronto-basal high grade glioma resection with 5-Aminolevulinic Acid use: Technical note

BackgroundGliomas are diffuse intra-axial lesions, which can be accessed by multiple surgical corridors for a same location depending on the surgeon's preference. 5-Aminolevulinic Acid use facilitates the extend of resection in case of high-grade gliomas, especially when differentiating normal brain from tumor periphery is challenging. MethodsComplete resection of glioblastoma via a supraorbital transciliary approach with 5-Aminolevulinic Acid use was performed without any complications, as demonstrated on postoperative MRI. ResultsPatient was discharged on the third postoperative day. Wound follow-up shows good cosmetic result. Patient underwent concomitant chemo-radiation (Temozolomide- 60Gy) and adjuvant chemotherapy (Temozolomide). No tumor recurrence was noted at six months follow-up. ConclusionIn selected cases, supraorbital transciliary approach could be proposed as primary approach as it provides the advantage of full control over all the vasculo-nervous structures at skull base without the necessity of protective brain retractor use while the 5-Aminolevulinic Acid use allows a gross total resection.

Is intramedullary pinning for isolated ulnar shaft fractures a surgical alternative to plate fixation?

IntroductionUnstable isolated ulnar shaft fractures are rare injuries that need to be surgically treated. The purpose of this study was to compare the functional and radiographic outcomes of two types of surgeries: closed reduction and intramedullary fixation (IMF) by pinning and open reduction and internal fixation (ORIF). HypothesisOur hypothesis was that IMF obtained similar outcomes to ORIF. Materials and methodsAll patients treated for an isolated distal or middle third ulnar shaft fracture between 2016 and 2019 were enrolled into two groups: ORIF and IMF. The technique performed depended on the surgeon's preference and not the type of fracture or patient. Demographic and clinical data (QuickDASH) and complications were retrospectively collected. X-rays were also examined to classify the fracture, assess postoperative reduction quality, and determine the amount of shortening and angulation. ResultsA total of 81 patients with a mean age of 34 years were divided into two groups: 34 in ORIF and 47 in IMF. The two groups had similar demographics, mechanisms of injury, and preoperative fracture characteristics. The only difference was smoking (p<0.001). Despite a greater mean ulnar shortening of 0.4 mm in the IMF group (p=0.048), there were no significant differences regarding the functional score (QuickDASH) and rate of pseudarthrosis. However, the operative time (p<0.001) was shorter in the IMF group. DiscussionIn the treatment of unstable isolated ulnar shaft fractures, IMF and ORIF had similar clinical and radiographic outcomes in terms of bone healing. The mean ulnar shortening reported in the IMF group was small and was not at risk of developing posttraumatic osteoarthritis. ConclusionIMF is a feasible therapeutic alternative to ORIF for isolated fractures of the distal two-thirds of the ulnar shaft. Further studies with a higher level of evidence need to be conducted to confirm the equivalence of these two fixation techniques. Level of evidenceIV, retrospective study.

Management and diagnosis of subretinal and suprachoroidal haemorrhage

AbstractSubretinal and suprachoroidal haemorrhage, particularly when central macula is involved, represent challenging clinical entities since their natural course, if left untreated, often leads to severe, progressive and irreversible vision loss, due to photoreceptor and retinal pigment epithelium (RPE) damage. Significant variation in prognosis and treatment of different types of haemorrhage dictates the need to establish the level of haemorrhage, which is primarily based on fundus appearance, as haemorrhage in different levels tends to present with a distinct configuration. Additional modalities, such as ultra‐sonography, optical coherence tomography, fluorescein angiography and focal electroretinography, contribute to diagnosis the clinical evaluation.Despite the wide range of techniques described for managing both subretinal and suprachoroidal haemorrhage, there is still no consensus among vitreoretinal surgeons on optimal approach. Pneumatic displacement with or without the intraretinal use of tissue plasminogen activator (t‐PA), pars plana vitrectomy with subretinal t‐PA and gas tamponade, pars plana vitrectomy and retinectomy for clot extraction and co‐treatment with anti‐vascular endothelial growths factors (anti‐VEGFs) and pars plana vitrectomy with choroidal blood drainage, have all been described as effective management approaches. Over the last few years, a trend towards a more timely and less invasive approach has emerged. However, the preferred technique is often determined by the level, the extent and duration of haemorrhage as well as surgeon preference.