Surgeons Plan Research Articles

Utility of cervical dynamic magnetic resonance imaging for evaluating patients with cervical myelopathy: a retrospective study.

Retrospective observational study. This study aimed to evaluate the utility of cervical dynamic magnetic resonance imaging (dMRI) in the assessment of cervical canal stenosis. Cervical spondylotic myelopathy has been intricately linked to both static and dynamic narrowing of the cervical spinal canal. Traditional MRI with the neck in a neutral position fails to identify the dynamic changes and may lead to misdiagnosis. Cervical dMRI is a promising tool for evaluating cervical myelopathy, enabling clinicians to assess spinal cord compression, segmental instability, and alterations in range of motion, often missed on conventional imaging. A retrospective analysis was conducted on 369 patients with symptoms of cervical myelopathy assessed using cervical dMRI. After assessing the subaxial cervical spine at each disc level (C3-T1), significant changes in the degree of central canal stenosis were determined. The appearance and extent of hyperintense lesions on T2-weighted sequences were also noted. Overall, 653/1,845 (35.39%) disc levels showed an increase in stenosis grade on extension MRI, with 168/653 (25.72%) and 180/653 (27.56%) disc levels changing from grades 0/1 to grades 2 and 3, respectively. Moreover, 120/369 (32.52%) patients showed a mean increase of 1.55±0.75 levels of compression on extension MRI when compared to neutral MRI. A fresh-appearing hyperintense lesion was observed in 79 (4.28%) disc levels on flexion MRI, which was not visualized on neutral MRI. Cervical dMRI may help surgeons plan for surgery, discuss the prognosis with the patient, and safeguard themselves from medico-legal issues arising from improper or missed diagnosis and treatment.

Automated Preoperative Planning Algorithm for Mandibular Angle Osteotomy Based on Anatomical Landmarks Detection: A Retrospective Study.

The aim of the study was to develop and evaluate an automated preoperative planning algorithm based on anatomical landmark point recognition for enhancing the efficiency and intelligence of preoperative planning for mandibular angle osteotomy. A retrospective cohort of 34 patients underwent preoperative planning with this algorithm. The present algorithm was developed using a method based on anatomical marker point recognition. The efficiency, symmetry, and safety of the automated preoperative planning and esthetics were statistically analyzed by paired t test and χ2 test. The results showed that the automated planning algorithm was able to achieve a great improvement in preoperative planning efficiency as well as safety and symmetry. A prospective case report of 2 patients is then reported, illustrating the safety and esthetics of the algorithm with 1-year postoperative follow-up and postoperative esthetic scores. This algorithm can help to improve the efficiency of preoperative planning for surgeons while ensuring safety and esthetics and can be further applied to other craniomaxillofacial personalized design surgeries in the preoperative design in the future.

Exploring arterial anatomy of the internal capsule: an analysis of the deep vascular structures and related white matter pathways.

The internal capsule is supplied by perforators originating from the internal carotid artery, middle cerebral artery, anterior choroidal artery and anterior cerebral artery. The aim of this study is to examine the vascular anatomy of the internal capsule, along with its related white matter anatomy, in order to prevent potential risks and complications during surgical interventions. Twenty injected hemispheres prepared according to the Klingler method were dissected. Dissections were photographed at each stage. The findings obtained from the dissections were illustrated to make them more understandable. Additionally, the origins of the arteries involved in the vascularization of the internal capsule, their distances to bifurcations, and variations in supplying territories have been thoroughly examined. The insular cortex and the branches of the middle cerebral artery on the insula and operculum were observed. Following decortication of the insular cortex, the extreme capsule, claustrum, external capsule, putamen and globus pallidus structures were exposed. The internal capsule is shown together with the lenticulostriate arteries running on the anterior, genu and posterior limbs. Perforators supplying the internal capsule originated from the middle cerebral artery, anterior cerebral artery, internal carotid artery and anterior choroidal artery. The internal capsule's vascular supply varied, with the medial lenticulostriate arteries (MLA) and lateral lenticulostriate arteries (LLA) being the primary arteries. The anterior limb was most often supplied by the MLA, while the LLA and anterior choroidal artery dominated the genu and posterior limb. The recurrent artery of Heubner originated mostly from the A2 segment. The distance from the ICA bifurcation to the origin of the first LLA on M1 is 9.55 ± 2.32mm, and to the first MLA on A1 is 5.35 ± 1.84mm. MLA branching from A1 and proximal A2 ranged from 5 to 9, while LLA originating from the MCA ranged from 7 to 12. This study provides comprehensive understanding of the arterial supply to the internal capsule by combining white matter dissection. The insights gained from this study can help surgeons plan and execute procedures including oncological, psychosurgical, and vascular more accurately and safely. The illustrations derived from the dissections serve as valuable educational material for young neurosurgeons and other medical professionals.

Integrating Artificial Intelligence Into the Visualization and Modeling of Three-Dimensional Anatomy in Pediatric Surgical Patients

BackgroundPediatric surgeons often treat patients with complex anatomical considerations due to congenital anomalies or distortion of normal structures by solid organ tumors. There are multiple applications for three-dimensional visualization of these structures based on cross-sectional imaging. Recently, advances in artificial intelligence (AI) applications and graphics hardware have made rapid 3D modelling of individual structures within the body accessible to surgeons without sophisticated and expensive hardware. In this report, we provide an overview of these applications and their uses in preoperative planning for pediatric surgeons. MethodsDeidentified DICOM files containing cross-sectional imaging of preoperative pediatric surgery patients were loaded from an institutional PACS database onto a secure PC with dedicated graphics and AI hardware (NVIDIA Geforce RTX 4070 laptop GPU). Visualization was obtained using an open-source imaging platform (3D Slicer). AI extensions to the platform were utilized to delineate the anatomy of interest. ResultsSegmentations of skeletal and visceral structures within a scan were obtained using the TotalSegmentator extension with an average processing time under 5 min. Additional AI modules were utilized for providing detailed mapping of the airways (AirwaySegmentation), lungs (Chest Imaging Platform), liver (SlicerLiver), or vasculature (SlicerVMTK). Other extensions were used for delineation of tumors within the hepatic parenchyma (MONAI Auto3DSeg) and hepatic vessels (RVesselX). ConclusionAI algorithms for image interpretation and processors dedicated to AI functions have significantly decreased the technical and financial requirements for obtaining detailed three-dimensional images of patient anatomy. Models obtained using AI algorithms have potential applications in preoperative planning, surgical simulation, patient education, and training. Level of EvidenceV, Case Series, Description of Technique.

Why Liquidity Matters: A Financial Planning and Investment Discussion for Plastic Surgeons.

Plastic surgeons should understand the importance of maintaining liquidity as part of a robust household financial planning and investment strategy. Although investors rightly focus on achieving solid long-term returns, our experience suggests that many plastic surgeons often pay too little attention to liquidity management in their outlook, and some may experience stress as a result. This article discusses why liquidity management matters both in terms of each surgeon's unique career and in the context of today's dynamic investment opportunities and risks. We also discuss how best to understand the trade-offs and costs associated with household debt. Finally, we present simple self-diagnostic questions to help surgeons assess whether their current financial planning addresses key liquidity risks. This article belongs to a series that introduces relevant wealth and investment subjects for practicing plastic surgeons, students in plastic surgery, and support function professionals. This discussion is not meant to be exhaustive nor constitutes investment advice regarding any asset class, strategy, or examples cited herein.

A Comparison of Amyloid Deposition in Endoscopic and Open Carpal Tunnel Release

Previous investigations assessing the incidence of amyloidosis detected with biopsy during carpal tunnel release (CTR) have focused on open CTR (OCTR). Prior authors have suggested that biopsy may be more technically challenging during endoscopic carpal tunnel release (ECTR). Our purpose was to compare differences in the incidence of amyloid deposition detected during ECTR versus OCTR. We reviewed all primary ECTR and OCTR during which a biopsy for amyloid was obtained between February 2022 and June 2023. All procedures were performed by five upper-extremity surgeons from a single institution. Congo red staining was used to determine the presence of amyloid deposition in either the transverse carpal ligament (TCL) or tenosynovium. All positive cases underwent subtype analysis and protein identification through liquid chromatography-tandem mass spectrometry. Baseline demographics were recorded for each case, and the incidence of positive biopsy was compared between ECTR and OCTR cases. A total of 282 cases were included for analysis (143 ECTR and 139 OCTR). The mean age was 67 years, and 45% of cases were women. Baseline demographics were similar except for a significantly higher incidence of diabetes in OCTR cases (13% vs 33%). Overall, 13% of CTR cases had a positive biopsy. There was a statistically significant difference in the incidence of amyloid deposition detected during biopsy in ECTR cases (3.5%) compared with OCTR cases (23%). Biopsy performed during ECTR may result in a lower incidence of amyloid detection. Future basic science investigation may be necessary to determine histologic differences between tenosynovium proximal and distal to the leading edge of the TCL. When surgeons plan a biopsy during surgical release of the carpal tunnel, an open approach may be advantageous. Prognostic II.

Pattern of Mandibular Third Molar Impaction in Patients from Twin Cities of Pakistan

When a tooth fails to erupt within its expected time window, it is called as impaction. Impaction of tooth can be due to multiple local and generalized reasons. Generalized factors are associated with multiple systematic disorders and syndromes including cleidocranial dysostosis, Down’s syndrome, amelogenesis imperfecta, osteopetrosis and achondroplasia. Local factors involved in the failure of eruption include lack of space, supernumerary teeth, odontogenic cysts and tumors, odontoma, ankylosis, existence of alveolar cleft and idiopathic factors such as primary failure of eruption. Mechanical obstruction are most frequently associated with the failure of eruption of permanent teeth. Most common impacted tooth is mandibular third molar which makes 98% of all types of impacted teeth1 followed be maxillary third molar, maxillary canine and mandibular second premolars. Mandibular third molars removal is performed due to multiple reasons including pain, swelling and other complications during and after eruption. Its extraction requires proper planning according to the angulation and position to avoid post-operative complication. The goal of the present study is to estimate patterns of mandibular impaction in patients from twin cities of Pakistan. So that surgeons can plan the surgery according to the patterns of impactions. A prospective survey was executed on patients visiting oral surgery section of Islamic International Dental Hospital, Islamabad from April 2018 to Feb 2019. Sample size was of 50 patients. Chosen Classifications were Pell and Gregory and Winters classification. Data examination was done through SPSS 23. The most frequent type of impaction is mesioangular in patients of twin cities. Third molar impaction is a public health concern. The most predominant category of impaction was level B and class 2, mesioangular impaction with a slight male prediction in twin cities of Pakistan. This study can help surgeons plan according to data and avoid complications.

Lower deltoid tuberosity indices are associated with the use of a stemmed instead of a preoperatively planned stemless implant

BackgroundAnatomic total shoulder arthroplasty (TSA) using a stemless prosthesis continues to increase in popularity as literature supporting their use grows. Intraoperative findings, however, may require switching from a planned stemless prosthesis to using a stemmed implant, yet literature attempting to understand the incidence and risk factors leading to this outcome is limited. The purpose of this study was to document the incidence of intraoperative change from a planned stemless implant to a stemmed prosthesis and to determine the correlation between the deltoid tuberosity index and this decision. MethodsAll patients scheduled to undergo TSA with a stemless humeral prosthesis between 2018 and 2023 at a single academic institution were retrospectively reviewed. Sociodemographic data, comorbidities, and preoperative deltoid tuberosity indices (DTI) were collected for review. DTI was used as an approximation for a patient’s bone mineral density. Surgeon plan for stemless TSA was verified via saved three-dimensional preoperative plans. ResultsNinety-two patients were scheduled to undergo stemless TSA, 8 (8.70%) of which received a stemmed implant based on intraoperative findings. In all cases, the operative surgeon deemed the metaphyseal bone inadequate to facilitate use of a stemless implant. DTI was significantly higher in the stemless group relative to the stemmed group (1.55 vs. 1.37, P = .0023). Discussion and ConclusionApproximately 9% of planned stemless TSA were converted to stemmed TSA due to proximal humerus bone insufficiency based on surgeon assessment at time of surgery. Diminished DTI was noted to be a risk factor. Preoperative planning may be improved by including imaging parameters to assess bone sufficiency (eg, DTI).

A radiological analysis of pelvic fixation trajectories: patient series.

Three well-defined methods for pelvic fixation are used for biomechanical support in spine fusion constructs: iliac, recessed iliac, and S2-alar-iliac (S2AI) screws. The authors compared the maximum screw sizes that could be placed with these techniques by using image-guidance software and high-resolution computed tomography scans from 20 randomly selected patients. Six trajectories were plotted per side, beginning at recognized starting points (standard or recessed posterior superior iliac spine [PSIS] or S2AI screw) and ending at the anterior inferior iliac spine (AIIS) or supra-acetabular notch (SAN). The mean maximum screw length and width ranged from 80.0 ± 32.2 mm to 140.8 ± 22.6 mm and from 8.25 ± 1.2 mm to 13.0 ± 2.7 mm, respectively, depending on the trajectory. Statistically significant differences in length were found between the standard and recessed PSIS trajectories to the AIIS (p < 0.001) and between the standard PSIS-to-AIIS trajectory and the S2AI-to-AIIS (p = 0.007) or S2AI-to-SAN (p < 0.001) trajectories. The most successful trajectory was the PSIS to SAN (95%, 38/40). The traditional iliac screw trajectory enabled the longest and widest screw trajectories and highest rate of successful screw placement with the fewest theoretical breaches more reliably than recessed and S2AI trajectories. These findings may help surgeons plan for maximum screw purchase for pelvic fixation.

Artificial intelligence: Friend or foe?

Artificial intelligence: Friend or foe?

How Does Preoperative Pure Tone Audiometry Relate to the Findings at Surgery to Explain the Hearing Status in Chronic Otitis Media?

Pure tone audiometry (PTA) guides surgical decision-making in chronic otitis media (COM), and PTA values depend upon the type and extent of COM. Our cross-sectional study included patients with COM with/without cholesteatoma who were scheduled for surgery. Findings on examination of the middle ear under the microscope and at surgery which could explain the hearing loss were corroborated with preoperative PTA through appropriate statistical methods. The study included 114 patients (mean age: 31.07 years; range: 7-57). Following preoperative PTA, 50% of patients had moderate hearing loss and ~73% had air-bone gap (ABG) <35 dB. Conductive hearing loss affected 109 patients (97.61%); five had mixed hearing loss. At surgery, 27 patients (23.68%) had ossicular discontinuity, with the incus being the most affected. Twenty-one patients in this group had ABG ≥35 dB. Perforations involving the anterior and posterior halves of the pars tensa, and subtotal perforations, demonstrated the maximum mean hearing loss [45.39±8.29 dB HL (p=0.075), 51.08±12.51 dB HL (p=0.26), respectively]. The mean pure tone average in the intact ossicles group was 43.62±8.07 dB HL and that in the absent/eroded ossicles group was 58.15±11.05 dB HL (p<0.0001); the mean ABG was 27.89±4.77 dB and 38.88±6.47 dB, respectively (p<0.0001). Hearing loss was significantly associated with the size but not the site of the central perforation. With ossicular discontinuity, hearing loss and ABG deteriorated significantly. The findings re-establish the relationship between preoperative PTA and the middle ear status which should help surgeons plan surgery and counsel patients regarding hearing outcomes.

Minimizing the Risk of Wrong-site Dermatologic Surgery: The Five "I"s Process.

INTRODUCTION Wrong-site surgery remains a problem in surgery despite the WHO surgical checklist,1 reported as one per 100,000.2 The current process is nonspecific and does not form part of the process management.2 NHS England reports that 27.4% of general surgical never events were related to wrong skin condition surgery.3 Within dermatologic surgery, this impacts skin lesions, assessed by one practitioner and excised by another, and is accentuated by the high-volume nature of these clinics. Anatomic risk factors include misperception of patient orientation or poorly visualized areas, for example, back, head, and neck. Patient risk factors include multiple lesions at a similar site or communication issues, for example, mental capacity or mental/ physical disabilities. Therefore, there is a need to refine the process. TECHNIQUE Here, we propose a simple five-step process, deemed the five I’s process, for all skin lesions: Ink—mark the patient preoperatively with the intended incision Image—use secure photography or the patient’s smartphone4 Inject local anesthetic along the markings Incise along the markings Illustrate the surgery graphically These principles also draw relevance to other surgical domains, for example, illustrating procedures with limited visualization, such as complex head and neck reconstruction, or marking a donor site for tendon reconstruction. Ink When consenting a patient, the incision should be marked. In skin cancer excision, marking an adequate margin of uninvolved skin often leaves a bigger defect than the patient anticipates. This also helps the surgeon plan a suitable reconstructive method. Image A photograph with a hospital-approved device or medical photography is helpful, enabling the patient to understand the surgical plan and help to provide informed consent. For reconstruction of a scalp defect, a local flap requires more extensive incisions resulting in a larger postoperative wound but is likely to be more aesthetic in the long term. However, a patient may prefer coverage with a skin graft despite a contour defect and no hair growth from the grafted area for a simpler wound. Consent must be taken beforehand to ensure patient privacy and data protection compliance. Photographs should be securely stored and accessed via a centralized system, which most centers have. The UK has no restrictions for photography using a patient’s phone; however, this practice varies from country to country. Inject The first pause in the WHO checklist is to avoid wrong-site injections. Local anesthetic should be infiltrated along the inked lines. Preoperative markings of local flaps/sites for skin grafts help anticipate the type and volume of local anesthetic required. Incise The second surgical pause of the WHO checklist is incise. Then, the skin should be cut along the marked lines. Illustrate An illustration drawn on the operation note clarifies the exact surgical site and reconstruction method. This documentation should be uploaded to a centralized system or be available during follow-up to aid continuity of care, particularly if done by another physician or by virtual means. CONCLUSION The five I’s process is a memorable method to supplement the WHO checklist and minimizes miscommunication between patients and surgeons, and therefore, wrong-site surgery (Fig. 1). (See Video [online], which displays the five I’s process in the preoperative management of a patient.)Fig. 1.: This figure details the five I’s process. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"This video displays the Five I’s in the preoperative management of a patient.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_4thb82k2"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}

Are the sinonasal outcome test and nasal obstruction symptom evaluation scale questionnaires suitable for assessing the quality of life after septorhinoplasty? A prospective case-control study

In the evaluation after septorhinoplasty (SRP), the surgeon's plan and the patient's expectations may not always be realised. Therefore, in our prospective case-control study, we aimed to investigate whether the Sinonasal Outcome Test (SNOT-22) and Nasal Obstruction Symptom Evaluation Scales (NOSE), which have been validated in different patient populations in Turkish, are appropriate for evaluating SRP cases and their relationship with each other. Preoperative and postoperative data of NOSE and SNOT-22 questionnaires of 125 cases diagnosed with traumatic septum deviation and external nasal deformity and decided to be operated were analyzed. It was calculated that the SNOT-22 score of those with high/low preoperative NOSE scores was also high/low with a 53.6% probability and that the SNOT-22 score of those with high/low postoperative NOSE scores was also high/low with a 69.9% probability, indicating a positive and high-level relationship between postoperative NOSE and SNOT-22 measurements. When the answers given to all questions in SNOT-22 were evaluated separately, it was observed that the most disturbing symptoms of the cases were nasal obstruction at 78.4% and the need to blow the nose at 46.4% in the preoperative period, and nasal obstruction with 64.8% and the need to blow nose with 37.6% in the postoperative period. The most dramatic changes in the answers to SNOT-22 questions were observed in the patient's feelings of frustrated/restless/irritable, sadness, and embrassed. SNOT-22 and NOSE questionnaires can be used interchangeably to evaluate the functional status of patients undergoing SRP surgery.

Varied Histomorphological Presentations of Appendiceal Neoplasms: A Case Series of Eight Cases

During routine histopathological study of appendicular specimens, we identified eight cases of appendiceal tumours, including five cases of Low-grade Appendiceal Mucinous Neoplasms (LAMN) and three cases of adenocarcinoma. Among the adenocarcinoma cases, one was a rare colorectal type adenocarcinoma in an older male and two were mucinous adenocarcinoma which includes a case of signet ring cell rich type. These tumours were classified and staged according to the recent WHO classification (5th edition) and the eighth edition of the American Joint Committee of Cancer (AJCC) staging manual. The median age in our series was 60 years. Serum markers were evaluated in two cases of Pseudomyxoma Peritonei (PMP), which showed elevated levels of CA-125 and CA 19.9 in each case. In this case series, three patients were initially diagnosed with acute appendicitis, one case as mucocele, two cases underwent surgery for ovarian malignancy, one patient was operated for an incisional hernia, and one patient was diagnosed with acute intestinal obstruction after clinical and radiological investigations. Histopathological examination confirmed the diagnosis of appendicular neoplasms in these eight cases. Meticulous histopathological examination of all appendectomy specimens is important for the proper diagnosis of appendicular neoplasms and to predict their severity. This will help surgeons plan further treatment to increase the patient's survival rate.

Ultrasound evaluation of a new surface reference line to describe sural nerve location and safe zones to consider in posterior leg approaches

PurposeSeveral authors have described methods to predict the sural nerve pathway with non-proportional numerical distances, but none have proposed a person-proportional, reproducible method with anatomical references. The aim of this research is to describe ultrasonographically the distance and crossing zone between a surface reference line and the position of the sural nerve.MethodsDescriptive cross-sectional study, performed between January and April 2022 in patients requiring foot surgery who met inclusion criteria. The sural nerve course in the posterior leg was located and marked using ultrasound. Landmarks were drawn with a straight line from the medial femoral condyle to the tip of the fibula. Four equal zones were established in the leg by subdividing the distal half of the line. This way, areas based on simple anatomical proportions for each patient were studied. The distance between the marking and the ultrasound nerve position was measured in these 4 zones, creating intersection points and safety areas. Location and distances from the sural nerve to the proposed landmarks were assessed.ResultsOne-hundred and four lower limbs, 52 left and 52 right, assessed in 52 patients were included. The shortest median distance of the nerve passage was 2.9 mm from Point 2. The sural nerve intersection was 60/104 (57.7%) in Zone B, 21/104 (20.1%) in Zone C and 19/104 (18.3%) in Zone A. Safety zones were established. Average 80.5% of coincidence in sural nerve localization was found in the distal half of the leg, in relation to the surface reference line when comparing both legs of each patient.ConclusionsThis study proposes a simple, reproducible, non-invasive and, for the first time, person-proportional method, that describes the distance and location of the main areas of intersection of the sural nerve with points and zones (risk and safe zones) determined by a line guided by superficial anatomical landmarks. Its application when surgeons plan and perform posterior leg approaches will help to avoid iatrogenic nerve injuries.Level of evidenceIV.

HPB V08 Fluorescence Image Guidance (FIG) in minimally invasive liver surgery- can it help identify deep margins?

Abstract Background Despite recent advances in imaging modalities and surgical techniques in liver resection, the rate of R1 resection in liver tumours is still high. Currently, liver surgeons plan the type of liver resection based on information gathered from pre-operative cross-sectional imaging, intraoperative naked eye examination/palpation, and intra-operative ultrasound (IOUS) examination. Naked eye examination and palpation help identify superficially located tumours; however, they do not help localise deeply seated small tumours or accurately mark tumour margins. Moreover, the lack of tactile feedback in the case of laparoscopic liver surgery makes tumour identification further difficult. Currently, IOUS is the most sensitive test for detecting liver tumours – in both open and laparoscopic liver surgery. However, it does not give a real-time visual clue on transection margins. Identification and marking of the deep margin of the tumour are not possible with IOUS. We describe the use of FIG using indocyanine green (ICG) dye in localisation and identification of deep margins of a segment seven liver metastasis. Methods We present a video demonstration of the use of FIG in the identification of deep resection margins of a segment seven tumour in a 41 year-old female patient. Initially, the tumour was not visible to the naked eye owing to its location, which made the identification of the tumour and its margins with IOUS challenging. We can see in the video how ICG identified the tumour readily and helped identify the resection margins, especially the deep margin, which was challenging to identify with IOUS. The histology report confirmed that all margins were free of tumours. Results We found that FIG is a robust, objective, real-time navigation tool that can overcome some of the shortfalls associated with and help accurately identify tumour resection margins. When used along with IOUS, we believe that FIG using ICG can potentially reduce R1 resection rates in liver tumours. Conclusions We found that FIG is a robust, objective, real-time navigation tool that can overcome some of the shortfalls associated with and help accurately identify tumour resection margins. When used along with IOUS, we believe that FIG using ICG can potentially reduce R1 resection rates in liver tumours.

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Imageless robotic-assisted total knee arthroplasty is accurate in vivo: a retrospective study to measure the postoperative bone resection and alignment.

Conventional instruments for total knee arthroplasty (TKA) have limited accuracy. The occurrence of outliers can negatively influence the clinical outcome and long-term survival of the implant. Orthopaedic robotic systems were developed to increase the accuracy of implant positioning and bone resections. Several systems requiring preoperative imaging have shown a higher degree of precision compared to conventional instrumentation. An imageless system needs less preoperative time and preparation and is more cost effective. Aim of this study was to find out whether this system is as precise, reproduces accurately the surgeon's planning and reduces the occurrence of outliers. This retrospective study included the first 71 robotic-assisted TKA and 308 conventional TKA in 374 patients. Intraoperatively planned and actual bone resections were compared. Postoperative alignment, measured on full leg weight bearing radiographs, was related to the respective planning and statistically compared between the groups. Baseline characteristics (age, BMI, ASA, preoperative Knee Society Score and deformity) between both groups were comparable. According to the planned alignment, the postoperative mean difference was -1.01° in the robotic versus 2.05° in the conventional group. The maximum deviation was -2/+ 2.5° in the robotic and -6.6/ + 6.8° in the conventional group. According to the plan, there were no outliers above ± 3° in the robotic versus 24% in the conventional group. The mean difference between planned and measured bone resection was 0.21mm with a maximum of 2mm. The 95% confidence interval was at each position 1mm or below. The described imageless robotic system is accurate in terms of coronal alignment and bone resections. In precision, it is superior to conventional instrumentation and could therefore be used to evaluate new alignment concepts.

Encrypted smartphone text messaging between spine surgeons may reduce after-hours surgery.

"After-hours" non-elective spine surgery is associated with increased morbidity. Decision-making may be enhanced by collaborative input from experienced local colleagues. At our center, we implemented routine use of a cross-platform messaging system (CPMS; WhatsApp Inc., Mountain View, California) to facilitate quality care discussions and collaborative surgical decision-making between spine surgeons prior to booking cases with the operating room. Our aim is to determine whether encrypted text messaging for shared decision-making between spine surgeons affects the number or type of after-hours spine procedures. We retrospectively compared the number, type and length of after-hours spine surgery over three time periods: (A) June 1, 2016-May 31, 2017 (baseline control); (B) June 1, 2017-May 31, 2018 (implementation of retrospective quality care spine rounds); and (C) June 1, 2018-May 31, 2019 (implementation of CPMS). A qualitative analysis of the CPMS transcripts was also performed to assess the rate of between-surgeon agreement for timing and type of procedure. The mean number of after-hours spine surgeries/month over the three study periods (A, B, C) was 10.83, 9.75 and 7.58 (p = 0.014); length of surgery was 41.82, 33.14 and 25.37h/month (p = 0.001). Group agreement with the attending spine surgeon plan was 74.3% overall and was highest for the most urgent and least urgent types of indications. Prospective (i.e., prior to booking surgery) quality care discussion for joint decision-making among spine surgeons using CPMS may reduce both the number and complexity of after-hours procedures.

Anatomy of the Sural Nerve in the Posterolateral Approach to the Ankle: A Cadaveric Study

Sural nerve injury may occur during the posterolateral approach to the ankle during fracture fixation. We aimed to map its location in a posterolateral approach in cadaveric specimens. A posterolateral approach was used in 28 cadaver legs with the incision made halfway between the medial border of the fibula and the lateral border of Achilles tendon, extending proximally from the tip of the lateral malleolus. The sural nerve was identified and the distance from the distal tip of the incision to where it crossed the incision proximally was measured. The mean distance was 3.4 ± 1.2 (range 0.5-7.0) cm. In 22 cases (78.5%), the distance from the lowest part of the incision to the inferior part of the nerve was between 2.7 and 4.5 cm. The nerve did not cross the incision in 2 cases. We have demonstrated that the sural nerve crossed the posterolateral incision between 2.7 and 4.5 cm proximal to the tip of the fibula in the majority of cases. However, there remains individual anatomical variation, and we would recommend that care should be taken to look for the nerve closer to the Achilles tendon proximally and nearer the fibula distally. We hope that this information can help surgeons plan their approach and minimize iatrogenic injury to the sural nerve.