Surgery Techniques Research Articles

Robotic-assisted reoperative benign foregut surgery

Foregut disorders including gastroesophageal reflux disease (GERD), hiatal hernia (HH), and achalasia are often treated operatively including anti-reflux surgery (ARS), fundoplication, and Heller myotomy (HM). Minimally invasive surgery has become the preferred technique to treat these disorders. These operations have an inherent risk of failure requiring reoperation. These redo operations are more difficult because adhesions and destruction of tissue planes impair visualization during dissection of the hiatus and the gastroesophageal junction (GEJ). Conventional laparoscopic techniques have been described for redo foregut surgery with good results. Surgical robotic systems provide an alternative minimally invasive approach that improves visualization, dexterity, and surgeon ergonomics in many operations. The robot can be used safely and effectively for redo foregut surgery. In this review, we discuss the robotic surgical technique for reoperative foregut surgery and discuss the approach to individual foregut diseases.

Comparative analysis of modified posterior mini-open surgery versus standard open posterior approach for adolescent idiopathic scoliosis correction: a prospective study.

Adolescent idiopathic scoliosis (AIS) surgery aims to achieve optimal deformity correction while minimizing complications. The standard open posterior approach (OS) is effective but associated with significant soft tissue disruption and prolonged recovery. The modified mini-open surgery (MS) technique offers a less invasive alternative, potentially reducing surgical morbidity while maintaining comparable correction. In this prospective comparative study, 60 Lenke type 1 AIS patients with single thoracic curves were randomized to MS (n = 30) or OS (n = 30) groups. The MS technique utilized three midline incisions, a muscle-splitting approach, and selective arthrodesis at instrumented levels. Outcomes included deformity correction, intraoperative blood loss, hospital stay, postoperative pain (VAS), scar satisfaction, fusion rates, and complications at 2 years. Both groups achieved comparable correction with no loss at 2 years (MS: 79.7% ± 8.0%; OS: 85.0% ± 7.4%; p > 0.05). The MS group had reduced intraoperative blood loss (383.3 ± 82.9mL vs. 720.2 ± 74.3mL; p = 0.019), shorter hospital stays (6.2 ± 0.3 vs. 7.4 ± 1.2days; p = 0.044), and lower VAS scores at discharge (2.9 ± 1.8 vs. 3.9 ± 1.4; p = 0.02) and 2 years (1.5 ± 0.5 vs. 2.0 ± 0.7; p = 0.03). Scar satisfaction was higher in the MS group (4.5 ± 0.3 vs. 2.8 ± 0.6; p = 0.02). No pseudoarthrosis or complications occurred in either group. The MS approach offers comparable correction to OS with reduced morbidity and superior cosmesis.

Effect of Bone Microstructure Derived From CBCT on the Accuracy of Robot-Assisted Implant Surgery: A Retrospective Study.

The aim of this study was to investigate the influence of bone microstructure on the accuracy of robot-assisted dental implant surgery. This retrospective study analyzed 52 patients who received robot-assisted implant surgery between January 2023 and October 2023. Cone beam computed tomography (CBCT) scans were used to evaluate bone microstructural parameters, including the bone volume (BV), tissue volume (TV), bone volume fraction (BV/TV), bone surface (BS), bone surface fraction (BS/BV), trabecular thickness (Tb.Th), and trabecular separation (Tb.Sp). Preoperative and postoperative CBCT data were used to evaluate implant accuracy, and the relationship between bone microstructure parameters and implant deviation including platform deviation, apex deviation, and angular deviation was statistically analyzed. In robot-assisted implant surgery, BS/BV was a potential facilitator of several implant deviations, while BV/TV and Tb.Th were potential inhibitors of apex global deviation and angular deviation, respectively. Implant deviations were divided into two groups of large and small deviations by median, and the receiver operating characteristic (ROC) curve analysis showed that Tb.Th had the largest area under the ROC for predicting large apex global deviation, 0.711 (p < 0.001), with an optimal cutoff value > 0.179, a sensitivity and specificity of 70.37% and 76.92%. The study concluded that bone microstructure might affect the accuracy of dental implant placement in robotic surgeries. Incorporating bone quality assessments into preoperative planning may enhance the precision and outcomes of implant procedures, highlighting the potential for further refinement in robotic-assisted dental surgery techniques. ClinicalTrials.gov identifier: ChiCTR2400085813.

Cervical pedicle screw placement with patient-specific 3D-printed guides: accuracy and safety in a clinical experience.

Cervical pedicle screw (CPS) instrumentation offers significant biomechanical advantages compared to lateral mass or transarticular fixation. Nonetheless, malpositioning complications constitute a relevant concern. Customized patient-specific 3D-printed templates have been developed to improve CPS placement accuracy and safety. The aim of this study is to present our experience with this surgical technique and its accuracy and safety in a clinical setting. This single-center retrospective observational study of prospectively collected data included patients undergoing CPS fixation surgery using a patient-specific 3D template guide system. All patients underwent a 3D-volumetric high-resolution CT scan of the cervical spine for preoperative surgical planning. Postoperative CT scans were used to evaluate pedicle perforation, CPS trajectories, and deviations between the planned and the actual screw position. A total of 115 CPS were implanted in 25 patients, with 107 (93.1%) of the screws completely placed inside the pedicle. Cortical breach within 2mm was observed in 8 (6.9%) cases, with no cases of more severe pedicle infractions or perioperative neurovascular complication. No differences of CPS accuracies were found between each metameric fusion level, and between monolateral or bilateral templates. Mean total deviations were 0.75mm vertically and 0.51mm horizontally at the screw entry point, and 0.72mm vertically and horizontally at the narrowest pedicle point. Mean total sagittal and transverse angular deviations were 2.94° and 3.04°, respectively. Cervical pedicle screw placement using patient-specific guides is safe and accurate, supporting the feasibility of this technique in posterior cervical spine fusion surgery.

Advanced Surgical Approaches for the Rejuvenation of the Submental and Cervicofacial Regions: A Literature Review for a Personalized Approach

The quest for surgical advancements regarding the enhancement of the submental and cervicofacial regions has witnessed a remarkable upsurge in recent years. Informed patients are actively seeking sophisticated plastic surgery techniques to achieve comprehensive rejuvenation in these specific areas. Common complaints expressed by these patients include sagging of the jawline, the emergence of deep perioral wrinkles, and the formation of “marionette lines” within the lower third of the face. Furthermore, the manifestation of age-related signs, including neck laxity, submental adipose accumulation, “witch’s chin” deformity, and weakened platysma musculature, are common within this anatomical region. This literature review aims to summarize recent technical improvements, historical evolution, indications, postoperative care, and challenges for facial rejuvenation of the lower third of the face and neck. The application of minimally invasive procedures as part of a comprehensive approach for an aging face will also be discussed. In this article, an extensive search of the available literature was conducted using leading databases, including PubMed and MEDLINE, with the keywords “neck lift”, “platysmaplasty”, “facial rejuvenation”, “medial platysmaplasty”, “lateral platysmaplasty”, “neck rejuvenation”, and “cervicofacial rejuvenation”.

Hiatal sling liver retraction technique in bariatric and upper gastrointestinal surgeries - Our 15 year experience with 1874 surgeries.

Liver retraction is an important aspect when performing minimal access surgeries, especially bariatric and upper gastrointestinal (GI) surgeries. Various liver retraction methods are available and have been tried. Here, we present our experience with our indigenous hiatal sling technique for liver retraction and compare it with Nathanson liver retractor which is a popular and commonly used liver retraction method. This is a retrospective observational study of 1874 patients who underwent bariatric and upper GI surgeries over the last 15 years since September 2009. A secondary study was conducted amongst the two groups of patients who underwent upper GI and bariatric surgeries using hiatal sling technique and Nathanson retractor system for liver retraction between January 2023 and October 2023. End points measured were time taken, conversions and complication along with liver function tests (LFTs) such as aspartate aminotransferase (AST) and alanine transaminase measured between the two groups pre- and postoperatively day 0, day 1, day 3 and day 7. In our series of 1874 patients, hiatal sling liver traction was possible without any difficulties in all except 2 patients with no associated liver injury and with adequate exposure. In the comparative study, patients in the hiatal sling group (Group B) had significantly lesser elevation in LFTs as compared to the patients in the Nathanson liver retraction group (Group A), with no adverse events in both the groups. Hiatal sling technique for liver retraction is an effective technique which provides adequate exposure of the hiatus and causes lesser liver insult compared to rigid liver retraction system like Nathanson liver retraction system. Hiatal sling does not interfere with surgeons' field causing less errors during surgery and thus making it more ergonomic friendly.

Disparity in Resource Utilization of motion-sparing Anterior Cervical Spine Surgery: An analysis of NSQIP® and PearlDiver® Database.

Widespread racial, gender-related, socioeconomic and insurance-related disparities have been widely implicated in the utilization of new and improved surgical techniques including various aspects spinal surgery. A comprehensive analysis of such disparities is lacking for motion-preserving techniques in cervical spine surgery. To explore the disparities in resource utilization of motion-sparing technology in cervical spine surgery. Retrospective Review of large database PATIENT SAMPLE: NSQIP® database from 2010-2021 and PearlDiver® database from 2010-2022 were queried. CPT codes for cervical disc arthroplasty (CDA), and anterior cervical discectomy and fusion (ACDF) were utilized to isolate the case records (Table 1 and 3). Pre-operative clinical, racial, and gender data were investigated utilizing NSQIP®. PearlDiver® was used for area-level family income, education, insurance status and unemployment. Chi-square, Kruskal-Wallis and logistic regression were used for univariable categorical, continuous and multivariable analyses, respectively. A total of 5,912 and 32,625 CDA cases and 69,701 and 526,851 ACDF cases were isolated from NSQIP® and PearlDiver®, respectively. 'Younger' age, 'Asian Pacific Islander' race and elective surgery (p<0.001), were associated with undergoing CDA in NSQIP® database. Presence of Type 1 diabetes, smoking and hypertension (HTN) (p<0.001) were associated with undergoing ACDF in NSQIP®. PearlDiver® database showed 'Younger' age, higher area-level 'Family Income', and a higher mean percent of patients with 'private health insurance' (p<0.001) were associated with undergoing CDA. Higher area level unemployment was associated with ACDF. Wide spread racial, gender-related, and socioeconomic disparities have been observed. Identification of these disparities is sentinel for implication of change in health-care policy mitigating issues such as underinsurance leading to establishment of health equity.

Socioeconomic disparities and trends in the utilization of regional and neuraxial anesthesia for pediatric femur fracture repair.

Pediatric femur fractures often necessitate surgical intervention, with pain management being critical for both immediate and long-term outcomes. Peripheral nerve blocks (PNBs) and neuraxial techniques are effective in providing targeted pain relief while minimizing systemic opioid exposure. Despite their benefits, the utilization of these anesthesia techniques in pediatric orthopedic surgeries is limited, particularly among socioeconomically disadvantaged patients. This study aims to evaluate the association between socioeconomic status (SES) and the use of regional and neuraxial anesthesia in pediatric femur fracture repairs, focusing on healthcare resource utilization (HRU) outcomes such as hospital length of stay (LOS), total hospital charges, and discharge disposition. Using the 2016-2020 NIS database, we identified 43,605 pediatric patients who underwent femur fracture repair. Only 1 % received PNB, and 0.1 % received spinal block (SB). Our analysis revealed that PNB was less likely to be administered to patients from lower SES backgrounds, those with subtrochanteric fractures, or those requiring delayed repair. Conversely, PNB was associated with reduced HRU, while SB was linked to increased HRU. The findings underscore significant disparities in the application of regional anesthesia, influenced by socioeconomic factors. Our study highlights the need for standardized guidelines and interventions to address these disparities, ensuring equitable access to effective pain management techniques in pediatric orthopedic care. Further research is warranted to understand the barriers to the utilization of PNB and to develop strategies to enhance its adoption, particularly among underserved populations.

A Novel Assistant-Free Technique for Ptosis Surgery: Combining Small Fish Hook Retractors and Frilled Drapes

A Novel Assistant-Free Technique for Ptosis Surgery: Combining Small Fish Hook Retractors and Frilled Drapes

Postamputation pain: a multidisciplinary review of epidemiology, mechanisms, prevention, and treatment.

Despite humanity's long experience with amputations, postamputation pain remains a highly prevalent, incompletely understood, and clinically challenging condition. There are two main types of postamputation pain: residual limb pain (including but not limited to the "stump") and phantom limb pain. Despite considerable overlap between the two, they also have distinct clinical features, risk factors, and pathophysiological mechanisms. Central, peripheral, and spinal mechanisms may all contribute to the protean manifestations of persistent postamputation pain; an improved understanding of these mechanisms will be essential to identify the most promising interventions for the prevention and treatment of postamputation pain. Although there are currently no standardized prevention or treatment recommendations for any type of postamputation pain, an evidence-based, multimodal strategy including pharmacological agents, nonsurgical procedures, surgery, complementary and integrative techniques, and assistive technologies may prevent the development of chronic postamputation pain after amputation and/or optimize treatment outcomes.

Prediction of the upright articulated spine shape in the operating room using conditioned neural kernel fields

Anterior vertebral tethering (AVT) is a non-invasive spine surgery technique, treating severe spine deformations and preserving lower back mobility. However, patient positioning and surgical strategies greatly influences postoperative results. Predicting the upright geometry from pediatric spines is needed to optimize patient positioning in the operating room (OR) and improve surgical outcomes, but remains a complex task due to immature bone properties. We propose a framework used in the OR predicting the upright spine geometry at the first visit following surgery in idiopathic scoliosis patients. The approach first creates a 3D model of the spine while the patient is on the operating table. For this, multiview Transformers that combine images from different viewpoints are used to generate the intraoperative pose. The postoperative upright shape is then predicted on-the-fly using implicit neural fields, which are trained from geometries at different time points and conditioned with surgical parameters. A Signed Distance Function for shape constellations is used to handle the variability in spine appearance, capturing a disentangled latent domain of the articulation vectors, with separate encoding vectors representing both articulation and shape parameters. A regularization criterion based on a pre-trained group-wise trajectory of spine transformations generates complete spine models. A training set of 652 patients with 3D models was used to train the model, tested on a distinct cohort of 83 surgical patients. The framework based on neural kernels predicted upright 3D geometries with a mean 3D error of 1.3±0.5mm in landmarks points, and IoU of 95.9% in vertebral shapes when compared to actual postop models, falling within the acceptable margins of error below 2 mm.

Comparison of different surgical techniques and anastomosis methods in short-term outcomes of right colon cancer: a network meta-analysis of open surgery, laparoscopic, and robot-assisted techniques with extracorporeal and intracorporeal anastomosis.

With the rapid development of minimally invasive surgical techniques, there remains considerable controversy regarding the choice of surgical approach and anastomosis method for patients with right-sded colon cancer (RSCC). This meta-analysis compared the short-term outcomes of open right colectomies (ORC), laparoscopic right colectomies with intracorporeal and extracorporeal anastomosis (LRC-IA and LRC-EA), as well as robot right colectomies with intracorporeal and extracorporeal anastomosis (RRC-IA and RRC-EA). A systematic search was conducted across PubMed (n = 549), Web of Science (n = 821), Embase (n = 591), and the Cochrane Central Register (n = 86) from January 2000 to August 2024. Studies comparing at least two of the surgical techniques for RSCC were included. The primary outcomes evaluated were overall complications, wound infection, ileus, and reoperation rates. Secondary outcomes included operative time, blood loss, hospital stay, time to resume diet, and conversion rates. A Bayesian network meta-analysis was performed. A total of 39 studies comprising 6098 patients were included. The results indicated that LRC-IA had the lowest overall complication rate (OR 0.65; 95% CI [0.41, 1.07]), while ORC had the highest. RRC-IA was most effective in reducing wound infection (OR 0.77; 95% CI [0.39, 1.35]), blood loss (MD 18.01; 95% CI [4.62, 40.87]), and hospital stay (MD 0.93; 95% CI [0.67, 1.31]), while also demonstrating advantages in preventing postoperative ileus (OR 0.47; 95% CI [0.05, 1.31]) and ensuring faster bowel function recovery (OR 0.80; 95% CI [0.44, 1.53]). The analysis demonstrates that for patients with RSCC, RRC shows better short-term outcomes compared to LRC and ORC, while IA also surpasses EA.

Reconstruction of the anterior abdominal wall using a myocutaneous flap from the tensor fasciae latae muscle in a patient with squamous cell carcinoma of the skin

The present study reports the case of a 59-year-old female patient admitted to the department due to advanced skin cancer in the lower abdominal region extending to the peritoneum. The patient was qualified for tumor resection with simultaneous reconstruction using flap surgery techniques, employing a tensor fasciae latae muscle flap. The intervention involved wide tumor resection aimed at maximizing the likelihood of achieving oncological radicality. Reconstruction was carried out using a propeller flap from the tensor fasciae latae muscle and a rotational musculocutaneous flap based on the external oblique muscle. The procedure concluded with a skin graft from the thigh, which covered the remaining tissue defect after flap harvesting. The described reconstruction technique was carefully planned, considering the defect's characteristics and the patient’s condition, highlighting the importance of individualized approaches in plastic surgery. This case illustrates the complexity of surgical procedures in cancer patients and the significance of avoiding foreign materials in the context of chronic infections.

Advantages of the modified colpocleisis operation in patients with atypical types of pelvic organ prolapse

Background: Currently, there is no general universal unified surgical treatment strategy for patients with pelvic organ prolapse. Considering the risks of installing mesh implants and the increasing incidence of implant-associated complications, mesh-free pelvic floor surgery techniques have become relevant again. A method was developed and introduced into clinical practice, which is an electrosurgical vaginal hysterectomy followed by vaginal suturing using a modified colpocleesis operation, which allows combining all the advantages of this method and at the same time minimizing the risks of cancer in the future. Aim: The aim of this study was to improve the results of surgical treatment in patients with rare, complicated and recurrent forms of pelvic organ prolapse. Materials and methods: This study included 140 patients diagnosed with pelvic organ prolapse. The main group consisted of 70 individuals with rare, severe and complicated cases of genital prolapse, who underwent surgical treatment using our modified colpocleisis operation. The control group comprised 70 other individuals with newly diagnosed uncomplicated cases of pelvic organ prolapse, who underwent surgical treatment using mesh implants. Results: All patients underwent planned surgical treatment. The operated patients were monitored for 1–5 years. In the main group, the effectiveness of the operation was 100%, while the effectiveness of surgical treatment with a mesh implant in the control group was 95.7%. All patients in the main group had complete tissue healing. There were no cases of long-term complications or relapses in any of the patients. Conclusions: the use of the modified colpocleisis operation for atypical types of pelvic organ prolapse is a highly effective method of prolapse correction. This, in combination with a simple execution technique, allows it for being offered as a basic method for vaginal access in patients without sexual activity.

Novel sequential proximal iliopsoas compartment block: A four-in-one block as a primary anaesthetic technique for intramedullary femoral nailing surgery: A retrospective study

Background and Aims: The fragile elderly population suffering from hip fractures presents an anaesthetic challenge; therefore, widening the armamentarium for surgical treatment should be sought. This retrospective study presents a new primary anaesthetic method for intramedullary femoral nailing (IMFN) surgery in the context of hip fracture: the sequential proximal iliopsoas compartment (SPIC) block. Methods: This single-centre retrospective study involved 25 patients aged 80 or older submitted to IMFN surgery. The patients were given a single-shot SPIC block using a total of 25 ml of ropivacaine 0.5% plus dexamethasone 8 mg administered sequentially in the proximal iliopsoas space, divided equally as per two different sites as a primary anaesthetic technique associated with moderate sedation. The outcome measure was the adequacy of the anaesthetic approach. The one-tailed Wilcoxon signed-rank test compared the preoperative numerical pain rating scale (NPRS) with the NPRS at 24 h and the pre-incision with the maximum intraoperative mean arterial pressure. Results: The patients were successfully anaesthetised, had no vasopressor consumption, had good surgical conditions, and had no complaints recorded. No tachycardia or hypertensive events were noted. No additional opioids were given. No statistically different values were observed when the pre-incisional and intraoperative mean arterial pressure values were compared (P = 0.52), and the preoperative NPRS compared with the NPRS at 24 h showed a statistically significant difference (P &lt; 0.001). Conclusion: The SPIC block combined only with moderate sedation permits adequate anaesthesia while avoiding the significant risk of neuraxial/sympathetic blockade.

A novel method of using indocyanine green fluorescence technique for nephron-sparing surgery

A novel method of using indocyanine green fluorescence technique for nephron-sparing surgery

Advances in understanding the effects of cardiopulmonary bypass on gut microbiota during cardiac surgery.

Cardiopulmonary bypass (CPB) is an indispensable technique in cardiac surgery; however, its impact on gut microbiota and metabolites remains insufficiently studied. CPB may disrupt the intestinal mucosal barrier, altering the composition and function of gut microbiota, thereby triggering local immune responses and systemic inflammation, which may lead to postoperative complications. This narrative review examines relevant literature from PubMed, Web of Science, Google Scholar, and CNKI databases over the past decade. Keywords such as "gut microbiota," "cardiopulmonary bypass," "cardiac surgery," and "postoperative complications" were employed, with Boolean operators used to refine the search results. The review examines changes in gut microbiota before and after CPB, their role in postoperative complications, and potential strategies for modulation to improve outcomes.

Long-term retention of the pedicled thymic flap after bronchial stump coverage.

This study aimed to assess the feasibility and retention rates of pedicled thymic flaps to enhance understanding of bronchial stump coverage. A retrospective analysis of 22 consecutive patients who underwent anatomical lung resection followed by bronchial stump coverage with pedicled thymic flaps between January 2017 and December 2022 was conducted. The procedure was performed using a minimally invasive 3-port video-assisted thoracoscopic surgery technique for all patients with no complications related to graft harvest or fixation. Postoperative retention of the engrafted flaps was evaluated in the 16 patients who underwent thin-slice computed tomography (CT) at least once after surgery. The majority of the postoperative CT examinations were performed for surveillance of lung cancer recurrence. The retention rates of pedicled thymic flaps were 100% at 60 days, 87% at 180 days, and 70% at one year post-surgery. Pedicled thymic flaps can be safely harvested using a minimally invasive approach, and the majority of engrafted flaps remain adjacent to the bronchial stump for more than one year. This technique may be a viable option for patients at high risk of a delayed bronchopulmonary fistula.

Retraction Note: Comment on "Wound closure techniques for spinoplastic surgery: a review of the literature".

Retraction Note: Comment on "Wound closure techniques for spinoplastic surgery: a review of the literature".

White matter connections within the central sulcus subserving the somato-cognitive action network.

The somato-cognitive action network (SCAN) consists of three nodes interspersed within Penfield's motor effector regions. The configuration of the somato-cognitive action network nodes resembles the one of the 'plis de passage' of the central sulcus: small gyri bridging the precentral and postcentral gyri. Thus, we hypothesize that these may provide a structural substrate of the somato-cognitive action network. Here, using microdissections of sixteen human hemispheres, we consistently identified a chain of three distinct plis de passage with increased underlying white matter, in locations analogous to the somato-cognitive action network nodes. We mapped localizations of plis de passage into standard stereotactic space to seed fMRI connectivity across 9,000 resting-state fMRI scans, which demonstrated the connectivity of these sites with the somato-cognitive action network. Intraoperative recordings during direct electrical central sulcus stimulation further identified inter-effector regions corresponding to plis de passage locations. This work provides a critical step towards improved understanding of the somato-cognitive action network in both structural and functional terms. Further, our work has the potential to guide the development of refined motor cortex stimulation techniques for treating brain disorders, and operative resective techniques for complex surgery of the motor cortex.