Surgical Advantages Research Articles

Surgical advantages of using 3D patient-specific models in high-energy tibial plateau fractures.

Treatment of tibial plateau fractures are difficult due to the intra-articular nature of the proximal tibia and extensive involvement of the soft tissue envelope. In this study, we investigated the surgical experience acquired using digitally designed life-size fracture models to guide as a template to place plates and screws in the treatment of tibial plateau fractures and anatomic reduction of joint. 20 tibial plateau frature patients were divided into two equal surgery groups as conventional versus 3D model assisted. The fracture line angles, depression depth, and preoperative/postoperative Rasmussen knee score were measured for each patient. The duration of the operation, blood loss volume, turniquet time and number of intraoperative fluoroscopy was 89.5 ± 5.9min, 160.5 ± 15.3ml, 74.5 ± 6min and 10.7 ± 1.76 times, for 3D printing group and 127 ± 14.5min, 276 ± 44.8ml, 104.5 ± 5.5min and 18.5 ± 2.17 times for the conventional group, respectively. 3D model-assisted group indicated significantly shorter operation time, less blood loss volume, shorter turniquet and fluoroscopy times, and better outcome than the conventional one. The customized 3D model was user friendly, and it provided a radiation-free tibial screw insertion. The use of these models assisted surgical planning, maximized the possibility of ideal anatomical reduction and provided individualized information concerning tibial plateau fractures.

High-Frequency Peripheral Nerve Stimulation for Craniofacial Pain.

Since the first successful use of high-frequency electrical stimulation of trigeminal branches for treatment of facial pain in 1962, neuromodulation techniques become well established but remain greatly underutilised. Most subsequent implantation techniques and commercial devices for peripheral nerve stimulation, available until the last decade, utilised frequencies in the range 1-100 Hz. With the commercial introduction of 10-kHz spinal cord stimulation, there has been renewed interest in peripheral applications of kHz frequency neuromodulation. High-frequency biphasic stimulation causes rapid onset, reversible conduction block in mammalian nerves which might be useful in human peripheral neuromodulation applications, but the conduction block induced at kilohertz frequencies may not be the only mechanism contributing to analgesia. We discuss likely mechanisms of action of high-frequency peripheral nerve stimulation and present several clinical examples of successful use of this modality in various facial pain conditions. A change to sub-threshold higher frequencies in the 10 kHz range adds a number of distinct advantages. The lack of paresthesias is welcomed by patients. The ability to place the stimulating electrode approximately 1 cm away from the targeted nerve has an anatomical and surgical advantage.

Neuroanatomical Determinants of Secondary Trigeminal Neuralgia: Application of 7T Ultra-High-Field Multimodal Magnetic Resonance Imaging

Seven-Tesla (7T) magnetic resonance imaging (MRI) has demonstrated value for evaluating a variety of intracranial diseases. However, its utility in trigeminal neuralgia has received limited attention. The authors of the present study applied ultra-high field multimodal MRI to two representative patients with secondary trigeminal neuralgia due to epidermoid tumors to illustrate the possible clinical and surgical advantages of 7T compared with standard clinical strength imaging. Techniques included co-registration of multiple 7T sequences to optimize the detection of potential concurrent neurovascular and neoplasm-derived compression. 7T MRI studies were performed using a whole body scanner. Two- and three-dimensional renderings of potential neurovascular conflict were created by co-registering time-of-flight angiography and T2-weighted turbo spin echo images in MATLAB and GE software. Detailed comparisons of the various field strength images were provided by a collaborating neuroradiologist (B.D.). 7T MRI clearly illustrated minute tumor-adjacent vasculature. In contrast, conventional, low-field imaging did not consistently provide adequate details to distinguish cerebrospinal fluid pulsatility from vessels. The tumor margins, although distinct from the trigeminal nerve fibers at 7T, blended with those of the surrounding structures at 3T. Two- and three-dimensional co-registration oftime-of-flight angiography with T2-weighted MRI suggested that delicate, intervening vasculature may have contributed to these illustrative patients' symptomatology. 7T provided superior visualization of vital landmarks and subtle nerve and vessel features. Co-registration of various advanced 7T modalities may help to resolve complex disease etiologies. Future studies should explore the extent to which this dual etiology might persist across tumor types and utilize diffusion-based techniques to quantify what microstructural differences might exist between patients with trigeminal neuralgia from varying etiologies.

Minimally Invasive Techniques for Hirschsprung Disease

Background: Surgical treatment of Hirschsprung disease (HD) evolved in the last decades with the introduction of new innovative minimally invasive techniques. The aim of present study is to compare the results from two centers, applying similar minimal access approaches, total transanal endorectal pull-through (TEPT) and laparoscopic-assisted transanal pull-through (LA-TAPT). Materials and Methods: Data of all patients admitted between January 2011 and December 2016 in two Italian referral Hospitals for HD were retrospectively collected and analyzed. Exclusion criteria were as follows: redo procedure, patients with total colonic aganglionosis (ileostomy), patients lost at follow-up, or missing data. Patients who underwent TEPT and LA-TAPT were compared for gestational age, birth weight, age and weight at surgery, associated malformation, genetic syndrome, length of hospital stay, and early postoperative complications (within 30 days). Statistical analysis: Fisher's test and Mann-Whitney test; statistical significance set at P < .05. Results: None of the patients who underwent TEPT required laparotomy or laparoscopic assistance. Patients who underwent TEPT had lower age (P = .001), lower body weight (P < .0001), a significant higher rate of associated congenital heart disease (P = .006), and longer postoperative stay. In addition, the prevalence of perianal dermatitis was higher in TEPT patients (17/61 [28%] versus 2/46 [4%], P = .001). The two groups were similar in terms of postoperative enterocolitis, redo surgery, anastomotic stenosis, and other infective complications. Conclusion: Both minimally invasive techniques allow surgical advantages and outcomes; TEPT avoids pneumoperitoneum and the transperitoneal approach, with no need for laparoscopic instrumentation. TEPT group had longer postoperative stay, probably due to the higher prevalence of associated cardiac anomalies, and higher prevalence of perianal dermatitis, probably due to the lower age at operation.

Feasibility and validity of double-arm specimen extraction method after partial lung resection in single-port thoracoscopic surgery.

Few previous reports have evaluated lung specimen extraction method or how to improve lung specimen extraction method, especially with single-port thoracoscopic surgery. We evaluated the feasibility and surgical advantages of double-arm lung specimen extraction method by comparing double-arm vs. single-arm specimen extraction times. We retrospectively analyzed data for 268 patients undergoing partial lung resection via single-port thoracoscopy and specimen extraction using a specimen extractor in the Union Medical College Hospital of Fujian Medical University from November 2017 to June 2018. We divided patients into groups based on the specimen location as an upper-lobe group (group I), lower-lobe group (group II), and lung-segment group (group III). We then performed a subgroup analysis based on the degree of collapse of the lung lobe specimens during extraction as follows: good in group IA and IIA, and poor in group IB and IIB. The double-arm method required statistically significantly less time than the single-arm method: (69.6±31.9 vs. 89.9±47.8 s, respectively, P=0.037). We found no significant difference in lung specimen extraction time for double-arm vs. single-arm extraction in group I, II, or III (P=0.093, P=0.153, P=0.174, respectively). We also found no significant difference in lung specimen extraction time between the two methods in group IA and group IIA (P=0.165, P=0.649, respectively). However, in groups IB and IIB, extraction time with the double-arm method was significantly shorter compared with the single-arm method (64.4±12.3 vs. 89.1±12.1 s, P=0.034 and 113.8±27.1 vs. 160.0±31.8 s, P=0.042, respectively). In single-port thoracoscopic partial lung resection, double-arm specimen extraction method is more convenient and can shorten sample extraction time, especially for upper- and lower-lung lobes with poor degree of collapse. Double-arm specimen extraction method is feasible and effective after single-port thoracoscopic partial lung resection.

P94. Anterior versus posterior approaches for idiopathic adolescent thoracolumbar scoliosis: a cost comparison

BACKGROUND CONTEXT Adolescent idiopathic thoracolumbar scoliosis (Lenke 5) can be operatively managed with anterior or posterior approaches. Each approach has unique surgical advantages and limitations. PURPOSE To compare direct costs associated with anterior and posterior operations for thoracolumbar scoliosis in children. STUDY DESIGN/SETTING Single-center retrospective cohort. PATIENT SAMPLE Adolescents who underwent anterior or posterior operations for thoracolumbar AIS (Lenke 5). OUTCOME MEASURES Total and direct costs. METHODS Consecutive review of adolescents (age>10 years) who underwent anterior or posterior operations for thoracolumbar scoliosis (Lenke 5) at a single institution by a single surgeon. Inclusion criteria included idiopathic scoliosis, curve magnitude >450, and non-structural thoracic scoliosis. Direct costs of the index hospitalization were identified from medical billing data. Not included in direct cost data were charges and surgeon fees. Costs data were stratified and compared based on the surgical approach using non-paired Student T-tests; p RESULTS A total of 17 children (average age 15.3±1.9 years, girls-13, average curve magnitude 51.10±6.20) were analyzed. Ages and curve magnitudes were statistically similar between anterior (n=10; boys 2, girls 8) and posterior (n=7; girls 5) operations. Anterior operations had significantly fewer levels fused (5±0 vs 6±0.9), significantly longer OR times (449±40 v. 308±26 mins), and more patients admitted to ICU post-op (30% vs 14%). While hospital lengths of stay (LOS) (5±2.1 v. 4±0.5 days) were not different, 2 anterior patients had LOS>7 days due to difficult pain control and C. diff colitis. Anterior operations were associated with significantly greater direct costs ($40,161±$3,668 v. $34,469±$7,846). However, when the 2 anterior patients with extended LOS were excluded, direct costs were not statistically different (anterior: $39,990±$3,855 v. posterior: $34,469±$7,846). In addition to room/board and ICU care, supplies/instrumentation, and operating room services were major drivers of cost irrespective of approach. CONCLUSIONS For thoracolumbar AIS treated by anterior or posterior approaches, major drivers of cost were supplies/instrumentation, OR services, room/board, and ICU. Anterior operations had significantly greater direct costs due to more ICU admissions postoperative and more episodes of prolonged LOS. Minimizing LOS, ICU admissions, and postoperative complications are important to contain costs. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The Future of Robotic Surgery in Pediatric Urology: Upcoming Technology and Evolution Within the Field.

Since the introduction of the Da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) in 1999, the market for robot assisted laparoscopic surgery has grown with urology. The initial surgical advantage seen in adults was for robotic prostatectomy, and over time this expanded to the pediatric population with robotic pyeloplasty. The introduction of three-dimensional visualization, tremor elimination, a 4th arm, and 7-degree range of motion allowed a significant operator advantage over laparoscopy, especially for anastomotic suturing. After starting with pyeloplasty, the use of robotic technology with pediatric urology has expanded to include ureteral reimplantation and even more complex reconstructive procedures, such as enterocystoplasty, appendicovesicostomy, and bladder neck reconstruction. However, limitations of the Da Vinci Surgical Systems still exist despite its continued technological advances over multiple generations in the past 20 years. Due to the smaller pediatric market, less focus appears to have been placed on the development of the smaller 5 mm instruments. As pediatric urology continues to utilize robotic technology for minimally invasive surgery, there is hope that additional pediatric-friendly instruments and components will be developed, either by Intuitive Surgical or one of the new robotic platforms in development that are working to address many of the shortcomings of current systems. These new robotic platforms include improved haptic feedback systems, flexible scopes, easier maneuverability, and even adaptive machine learning concepts to bring robotic assisted laparoscopic surgery to the next level. In this report, we review the present and upcoming technological advances of the current Da Vinci surgical systems as well as various new robotic platforms, each offering a unique set of technological advantages. As technology progresses, the understanding of and access to these new robotic platforms will help guide pediatric urologists into the next forefront of minimally invasive surgery.

Is extralevator abdominoperineal resection necessary for low rectal carcinoma in the neoadjuvant chemoradiotherapy era?

Background: We aimed to compare the short-term surgical and early surgical oncological outcomes of abdominoperineal resection (APR) and extralevator APR (ELAPR) in patients with low rectal carcinoma that have received neoadjuvant chemoradiotherapy (NACRT), whose abdominal procedures were performed laparoscopically.Methods: One hundred and four patients who underwent APR or ELAPR for stage II/III low rectal carcinoma NACRT between 2013 and 2016 were evaluated by reviewing the standard charts for colorectal carcinoma.Results: Median follow-up for patients in APR group was 56 months(24–67 months) and 52 months(27–64 months) for ELAPR group. The postoperative complication rates were higher in ELAPR than in APR (perineal wound infection 38% vs. 22.5%(p = .03), perineal wound dehiscence 57% vs. 25%(p = .01), persistent perineal pain 28.5% vs. 13%(p = .01), urinary dysfunction 23% vs. 14.5%(p = .02), reoperation 16.5% vs. 4.8%(p = .03), respectively). Circumferential resection margin positivity, the number of lymph nodes dissected, and the rate of intra-operative perforation of the tumor were similar for both surgical techniques. Local recurrence rates at postoperative 2 years were also similar after APR and ELAPR (8% vs. 9.5%, p = .2).Conclusion: We conclude that in the era of routinely used NACRT, ELAPR is not superior to conventional APR for stage II/III low rectal carcinomas. ELAPR is associated with increased morbidity and has no short-term surgical oncological advantage over APR.

A randomized controlled trial comparing surgical excisional biopsies using CO2 laser, Er:YAG laser and scalpel

This randomized controlled trial (RCT) (ClinicalTrials.gov ID: NCT03001791) compared excisional biopsies of fibrous hyperplasia performed using a CO2 laser (140Hz, 400μs, 33mJ), Er:YAG laser (35Hz, 297μs, 200mJ, air–water cooling), or scalpel (15c blade). Clinical parameters recorded were duration of the intervention, intraoperative bleeding, need for electrocauterization and/or suturing, postoperative side effects, complications, pain, and intake of analgesics. Histopathological linear measurements of the thermal damage zone were performed on the laser biopsies. Results showed that the duration of the intervention was significantly shorter for both lasers compared to the scalpel (P<0.001). Intraoperative bleeding occurred less frequently with the CO2 laser (P<0.001). Additional electrocautery was used in 92% of Er:YAG laser interventions (P<0.001). Postsurgical complications, pain, and the intake of analgesics did not differ between the groups. The measured thermal damage zones differed significantly between the CO2 laser (median of 72.6μm) and Er:YAG laser (30.9μm) (P<0.001). This RCT showed that CO2 laser, Er:YAG laser, and scalpel are all adequate for excisional biopsies of small lesions in the oral mucosa. While patient postoperative morbidity is similar, the ideal instrument can be selected according to the surgical advantages preferred for the individual situation.

Abstract ES7-2: Practical approach to the axilla after neoadjuvant chemotherapy: What the clinical trials don't address

Abstract Neoadjuvant chemotherapy (NAC) was initially used in patients with inoperable breast cancer to improve resectability, but it is also beneficial in women with operable breast cancer, particularly with respect to the axilla. Nodal pathologic complete response (pCR) rates among clinically node-positive patients treated with modern systemic therapy range from 35-49%. The ability to downstage the axilla and potentially avoid axillary lymph node dissection (ALND) is one of the greatest surgical advantages of NAC. The optimal approach to the axilla after NAC varies based on the clinical nodal stage prior to NAC. In clinically node-negative patients, the use of sentinel lymph node biopsy (SLNB) after NAC has been well studied, with high identification rates and false-negative rates that are similar to the upfront surgery setting. In addition, regional recurrence rates are no different between clinically node-negative patients treated with SLNB alone after NAC, or those treated with upfront SLNB. In clinically node-positive patients, 3 single-arm prospective trials have demonstrated that SLNB after NAC results in a false-negative rate &amp;lt;10%, provided that the SLN technique is optimized with the use of dual mapping and retrieval of ≥3 negative SLNs. However, not all clinically node-positive patients are candidates for downstaging to SLNB with NAC. The prospective trials primarily enrolled patients with cT1-3N1 disease, and therefore study results should not be extrapolated to those patients presenting with cT4 and/or cN2/N3 disease, where ALND remains the standard of care. A more complicated issue is whether all clinically node-positive patients should even be considered for NAC, as the response rates in the nodes vary based on tumor subtype. Patients with hormone receptor (HR) positive/HER2 negative cancers have the lowest rates of nodal pCR compared to HER2 positive and triple-negative breast cancers. Specifically, patients with invasive lobular cancers have a low probability of nodal pCR with NAC, raising the question as to whether NAC should even be considered in these patients due to limited surgical downstaging. As all patients in the prospective trials had an ALND, the frequency with which ALND could be avoided with the use of NAC in clinically node-positive patients was not addressed, although more recent data have demonstrated that approximately 50% will achieve a nodal pCR and avoid ALND. Indications for ALND after NAC include any positive SLN (including micrometastases and isolated tumor cells), failed mapping, or patients presenting with inoperable breast cancer. Nodal recurrence rates among clinically node-positive patients treated with SLNB alone after NAC are largely unknown, with only one small study demonstrating low regional recurrence rates. Ultimately, the optimal treatment strategy to avoid ALND in patients with operable breast cancer is complex and based on a combination of tumor subtype, clinical nodal status, and type of breast surgery performed. With the continued use of modern systemic therapy and improved radiation techniques for breast cancer, our ability to de-escalate surgical care and reduce the morbidity of surgery, while still maintaining excellent disease control, has become our new standard of care. Citation Format: Barrio A. Practical approach to the axilla after neoadjuvant chemotherapy: What the clinical trials don't address [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr ES7-2.

Effect of surgical approach on node harvest in gastrectomy: Analysis of the National Cancer Database.

47 Background: Recent studies demonstrate significant surgical outcome advantages for patients undergoing minimally invasive versus open gastrectomy. Lymph node harvest at the time of gastrectomy is an indicator of adequate surgical resection and greater harvest is associated with improved staging and patient outcomes. Our aim is to evaluate lymph node harvest based on surgical approach. Our hypothesis is that a minimally invasive approach, particularly robot-assisted, will be associated with higher lymph node harvest. Methods: Patients undergoing gastrectomy for gastric adenocarcinoma in the period of 2010-2015 were identified using the National Cancer Database (NCDB). Data collected includes demographic data, institutional volume, approach, type of gastrectomy, tumor size, tumor location, pathologic T classification, year of diagnosis, Charlson-Deyo score and node harvest. Outcomes for patients undergoing open, laparoscopic, and robot-assisted gastrectomy were compared with univariate analysis and with a multivariate generalized linear mixed model (GLMM). Results: 19,555 patients were identified. There were 12,400 men (63.4%) and the mean age was 66.3 ± 12.5 years. 13,486 (69.0%) patients underwent open gastrectomy, 5,023 (25.7%) laparoscopic gastrectomy, and 1,046 (5.3%) robotic-assisted gastrectomy. Mean node harvest for open was 16.1 ± 11.5, laparoscopic was 15.1 ± 12.1, and robotic-assisted was 17.2 ± 13.3. Using a GLMM which controlled for the above listed covariates, robotic-assisted gastrectomy was associated with higher node harvest than both open (p = 0.041) and laparoscopic (p &lt; 0.001) while open was associated with higher node harvest than laparoscopic (p &lt; 0.001). There were 1582 operations with zero nodes harvested. In a sub-analysis of resections where at least one node was harvested (n = 17,973), the mean node harvest for open was 16.9 ± 11.1, laparoscopic was 17.5 ± 11.2, and robotic was 19.7 ± 12.3. Conclusions: This data suggests that a robot-assisted approach is associated with increased node harvest compared to laparoscopic and open approach in gastrectomy.

Mechanical testing of scapular neck fracture fixation using a synthetic bone model

BackgroundTrauma can fracture the scapular neck. Typically, a single plate along the lateral scapula border affixes the glenoid fragment to the scapula. This method is limited by difficulty in screw placement, frequent excessive soft tissue dissection, and risk for neurovascular injury. Substituting 2 smaller plates bridging the scapular neck mitigates these limitations, but no comparative mechanical data between techniques exists. Therefore, we compared the mechanical properties of two constructs securing a simulated scapular neck fracture. MethodsTwenty synthetic human scapulae underwent a templated scapular neck fracture. Repairs were performed with a single plate on the lateral scapular border (Column method), or two small plates parallel to the lateral border (Neck method). Measures of displacement, force, and stiffness were quantified during cyclic testing (20–150 N, 1 Hz, 1000 cycles) and loading to failure. Statistical comparisons were made with t-tests (p ≤ 0.050). FindingsThe column constructs had higher displacements than neck constructs after 1000 cycles, but differences were small (mean) 0.18 (SD 0.01) vs. 0.15 (0.02) mm (p ≤ 0.004). Cyclic stiffness was 655 (43) and 790 (88) N/mm for the column and neck constructs, respectively (p ≤ 0.003). Both techniques performed comparably in failure loading: at 1 mm of gap reduction the compressive loads were 426 (61) N and 428 (48) N and stiffness was 354 (129) and 334 (80) N/mm for the column and neck constructs, respectively. InterpretationGiven the surgical advantages, the neck fixation may be more suitable without biomechanical compromise compared to traditional lateral column fixation.

Research progress in treatment of tibial plateau fractures with primary total knee arthroplasty in the elderly

Tibial plateau fractures are intra-articular fractures of the knee. Restoring the articular surface, axis of lower extremities and function of knee is the main goal of treatment. Open reduction and internal fixation remains the gold standard for the treatment. However, it is more difficult to treat fractures in elderly patients with severe osteoarthritis, osteoporosis, and comminuted knee joints. Open reduction and internal fixation are sometimes difficult to achieve the treatment goal, and the patients are prone to bed-related complications. Total knee arthroplasty (TKA) is the main method for the treatment of traumatic arthritis after knee fracture, but the surgery is difficult with multiple complications. At present, some authors have applied primary TKA to the tibial plateau fractures and reported the advantages including immediate post-operative knee stability, early functional exercise and weight-bearing activities, and no need to consider the meniscus retention, cruciate ligament repair and articular anatomical reduction. This article reviews the surgical advantages, surgery-related issues and expenses to discuss the treatment of tibial plateau fractures in the elderly with TKA, providing reference for the treatment of tibial plateau fractures in the elderly. Key words: Tibial fractures; Arthroplasty, replacement, knee; Aged

Pterional, Pretemporal, and Orbitozygomatic Approaches: Anatomic and Comparative Study

Although pterional craniotomy and its variants are the most used approaches in neurosurgery, few studies have evaluated their precise indications. We evaluate the pterional (PT), pretemporal (PreT), and orbitozygomatic (OZ) approaches through quantitative measurements of area, linear, and angular exposures of the major intracranial vascular structures. Eight fresh, adult cadavers were operated with the PT, followed by the PreT, and ending with the OZ approach. The working area, angular exposure of vascular structures and linear exposure of the basilar artery were measured. The OZ approach presented a wider area (1301.3 ± 215.9 mm2) with an increase of 456.7 mm2 compared with the PT and of 167.4 mm2 to the PreT (P= 0.011). The extension from PT to PreT and OZ increases linear exposure of the basilar artery. When comparing the PreT and OZ, we found an increase in the horizontal and vertical angle to thebifurcation of the ipsilateral middle cerebral artery (P=0.005 and P= 0.032, respectively), horizontal angle to the basilar artery tip (P= 0.02), and horizontal angle to the contralateral ICA bifurcation (P= 0.048). The OZ approach offered notable surgical advantages compared with the traditional PT and PreT regarding to the area of exposure and linear exposure to basilar artery. Regarding angle of attack, the orbital rim and zygomatic arch removal provided quantitatively wider exposure and increased surgical freedom. A detailed anatomic study for each patient and surgeon experience must be considered for individualized surgical approach indication.

Contralateral Transfalcine Versus Ipsilateral Anterior Interhemispheric Approach for Midline Arteriovenous Malformations: Surgical and Anatomical Assessment

The contralateral anterior interhemispheric approach (CAIA) is considered to provide surgical advantages to access deep midline lesions: wider working angle, gravity enhanced dissection and retraction, more efficient lighting, and ergonomics. Our team has previously published on the merits of using a contralateral trajectory for medial frontoparietal arteriovenous malformations (AVMs) compared with the conventional anterior interhemispheric approach (IAIA). In this article, we compare the IAIA and CAIA for the resection of medial frontoparietal AVMs using quantitative surgical and anatomical analysis. Two models were designed mimicking the most common features of midline AVMs. The CAIA and IAIA were performed bilaterally in 10 specimens. Variables to compare technical feasibility (surgical window [SW] and surgical freedom [SF], target exposure, and angle of attack) were independently assessed using stereotactic navigation. The average SW, SF, and angle of attack were compared with the Student t test. Significance threshold was set at 0.05. The CITA and IAIA were similar in terms of SW, target exposure, and SF in the superior aspect of the AVM. In the depth of the interhemispheric fissure, the CAIA was significantly superior to IAIA in both AVM models: 77% wider AA for the inferior aspect of the AVM (P < 0.01) and greater SF for the draining vein (54%, P= 0.01), ipsilateral (98%, P= 0.02), and contralateral ACA (117%, P < 0.01). This study suggests technical superiority of the CAIA for the resection of deep midline AVMs. No objective difference was noted in the superficial areas of our models, denoting that IAIA is a safer choice for superficial AVMs. Our results set the foundation for further clinical analysis comparing both approaches.

Risk factors for additional port insertion in single-port laparoscopic appendectomy.

IntroductionSingle-port laparoscopic appendectomy (SPLA) was expected to have reduced risk of wound infection, less postoperative pain, and improved patient’s satisfaction with better cosmesis compared with conventional laparoscopic appendectomy (CLA). When SPLA is converted to CLA, the additional incision for another port insertion can lead to a decrease in the surgical advantages and clinical benefit.AimTo evaluate risk factors for conversion to CLA during SPLA.Material and methodsBetween August 2015 and December 2016, patients who underwent intended SPLA were retrospectively reviewed. Conversion was defined as any insertion of an additional port, and complicated appendicitis was defined as gangrenous or perforated appendicitis, abscess, or peritonitis in preoperative computed tomography. Postoperative complication was defined as any deviation in the routine postoperative course within 30 days postoperatively.ResultsOf 409 patients, 65 (15.9%) were treated with additional port insertion. The overall complication rate was 1.5% in each group, of which 1 patient developed superficial SSI and 4 patients developed deep surgical site infections in the SPLA group. After univariable and multivariable analysis, old age, male sex, increased serum C-reactive protein (OR = 2.944; 95% CI: 1.433–6.047; p = 0.003), and complicated appendicitis (OR = 3.330; 95% CI: 1.304–8.503; p = 0.012) were significant risk factors for conversion to CLA.ConclusionsThe conversion rate to CLA was 15.9%. Serum C-reactive protein level and complicated appendicitis were strong predictive factors for conversion from SPLA in acute appendicitis.

Energy-Based Tissue Fusion for Sutureless Closure: Applications, Mechanisms, and Potential for Functional Recovery.

As minimally invasive surgical techniques progress, the demand for efficient, reliable methods for vascular ligation and tissue closure becomes pronounced. The surgical advantages of energy-based vessel sealing exceed those of traditional, compression-based ligatures in procedures sensitive to duration, foreign bodies, and recovery time alike. Although the use of energy-based devices to seal or transect vasculature and connective tissue bundles is widespread, the breadth of heating strategies and energy dosimetry used across devices underscores an uncertainty as to the molecular nature of the sealing mechanism and induced tissue effect. Furthermore, energy-based techniques exhibit promise for the closure and functional repair of soft and connective tissues in the nervous, enteral, and dermal tissue domains. A constitutive theory of molecular bonding forces that arise in response to supraphysiological temperatures is required in order to optimize and progress the use of energy-based tissue fusion. While rapid tissue bonding has been suggested to arise from dehydration, dipole interactions, molecular cross-links, or the coagulation of cellular proteins, long-term functional tissue repair across fusion boundaries requires that the reaction to thermal damage be tailored to catalyze the onset of biological healing and remodeling. In this review, we compile and contrast findings from published thermal fusion research in an effort to encourage a molecular approach to characterization of the prevalent and promising energy-based tissue bond.

Subvastus Lateralis Approach to Total Knee Arthroplasty – A Cadaveric Evaluation

BackgroundTotal knee arthroplasty (TKA) has been a reliable method for effectively treating advanced knee arthropathy. A medial parapatellar approach (MPA) is commonly used because of its large exposure and versatility; however, iatrogenic soft tissue damage remains a concern. In response, several alternative approaches have emerged that aim to reduce soft tissue damage, though their clinical usefulness is often limited by poor surgical exposure of the internal compartments of the knee. Based on the relevant surgical anatomy of the knee, we propose the subvastus lateralis approach (SLA) as a novel alternative. The aim of the present study is to explore the anatomical and surgical advantages of using the SLA compared to the MPA for TKA.MethodsTo compare surgical effectiveness, a TKA was conducted on 22 paired fresh‐frozen cadaveric limbs (five females/six males) randomly assigned to either the SLA or MPA. All procedures were conducted by the same experienced surgeon. Primary parameters measured were the perimeter of surgical exposure as well as the length of skin incision. Additionally, subjective observations of the medial and lateral patellar contact were noted to assess patellar tracking. Afterwards, gross dissection of the limb was conducted to analyze any disruptions in the following soft tissues: components of the extensor mechanism, iliotibial band, tendon of the popliteus, and medial/lateral collateral ligaments.ResultsThe SLA provided adequate exposure to the internal compartments of the knee that was not statistically different to the mean exposure perimeter achieved using the MPA (p&gt;0.05). Furthermore, the exposure provided by the SLA was achieved using a skin incision that was not statistically different compared to the MPA (p&gt;0.05). In addition, patellar tracking showed superior results, where proper tracking was obtained in 100% of the SLA cases compared to 50% of those having undergone the MPA. Preliminary observations show that the SLA is successful in sparing the quadriceps tendon and the majority of the vastus lateralis. Conversely, in a subset of cases, the patellar ligament sustained a 0.1–0.7 mm transverse disruption of its distal fibers during the cutting of the tibial plateau.ConclusionThe SLA to TKA was able to be successfully completed in 100% of the specimens, with no major modifications to the technique. This approach proved to be reliable in knees with no notable deformities (valgus or varus) and provided an equal exposure to the internal compartments of the knee when compared to the standard MPA. It is important to note that this exposure was achieved using a skin incision of similar length to the MPA. The SLA also shows promising results regarding proper patellar tracking, though future investigation should be conducted to objectively assert these benefits. Finally, preliminary results show a reduction in the disruption of the quadriceps tendon and muscles when using the SLA, however, damage to the patellar ligament may occur. Future studies should evaluate the versatility of the SLA through an examination of specimens with a known degree of knee deformity.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Application of silicone implants in mammoplasty (literature survey)

In the article literature data concerning indications to placement of silicone breast implants in plastic surgery are presented. Peculiarities of preoperative preparation of patients aimed at prevention of postoperative complications are considered. The technique of surgical intervention, advantages and disadvantages of different methods are described. Difference in choice of surgical approach and positioning of implant relative to mammary gland are considered. Recommendations are given on selection of the type of implant, on determination of the volume of supposed silicone breast-implant prostheses, and also on the choice of optimal access for their insertion. The early and long-term complications and measures proposed by the authors for their elimination are studied. According to different studies, the commonest complication of the augmentation mammoplasty is contracture of the fibrous capsule surrounding the implant that requires surgical correction. One of main complications of all kinds of augmentation mammoplasty is secondary ptosis of mammary gland. A common complication of the augmentation mammoplasty is incorrect position of implants such as their asymmetry and location on different levels. In case of tubular breast a double inframammary fold may result unless tubularity of areola is corrected. Authors think that a significant number of unsolved problems concerning augmentation mammoplasty, optimal surgical approach, existence of the immediate and long-term complications are reasons for further study of augmentation mammoplasty. Increased dissatisfaction of patients with long-term results of augmentation mammoplasty, necessity to prevent such complication as fibrous contracture, create an urgent need for search of new methods. Thus, application of silicone implants in augmentation mammoplasty requires further study with the aim of optimization of the final aesthetic and clinical result.

Research advance in the operating treatment of primary cannaliculits

Recently, with the extensive use of endoscopic technology, polymer materials and other medical equipments, great progress and constant perfection have been achieved in the operating treatment of primary cannaliculits.Many new treatment methods are applied in clinical practice, such as canalicular incision, canalicular incision and silicon tube implants, resection of anterior canalicular wall and lacrimal stent intubation, and operating treatment with lacrimal endoscope.In this article, the surgical techniques, clinical practices, advantages and disadvantages of the therapies are summarized, and the existing problems are pointed out. Key words: Ophthalmologic surgical procedures; Comparative effectiveness research