Surgical Dissection Research Articles

Clinical and Radiographic Outcomes of Nitinol Compression Staples for Midfoot and Chopart Arthrodesis

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Continuous compression implant (nitinol staples) use in orthopaedic surgery has increased in recent years. There are several advantages of nitinol staples, including a lower profile when compared to traditional fixation methods. They are easy to apply and take up a smaller footprint than most plating techniques, thus decreasing surgical time and dissection. Additionally, continuous compression across the fusion site is maintained during the resorptive phase of bone healing. Biomechanical studies provide useful data supporting the use of nitinol staples in the foot and ankle; however, clinical data is limited. This study’s purpose is to determine the efficacy of nitinol staples to achieve stable, bony healing in midfoot and Chopart joint arthrodesis, and examine their clinical outcomes, complications, and pain scores. Methods: A retrospective chart review was performed on 127 midfoot/Chopart joints (71 patients) that underwent arthrodesis using nitinol staples in isolation over a five-year period (January 2017 – February 2022). The primary outcome variable was radiographic evidence of healing. Radiographs were blinded, randomized, and independently reviewed by three board certified foot and ankle surgeons. Each investigator reviewed digital radiographs independently and recorded their radiographic finding responses. Fusions were deemed healed if greater than 50% of the arthrodesis site contained bridging bone. A partially healed arthrodesis was defined as some bridging bone, but less than 50% of the overall arthrodesis site, and a nonunion was defined as no healing seen radiographically or loss of reduction. There were no cases of complete inter-surgeon radiographic disagreement in this study. Pain scores and clinical outcomes were also collected. Smokers and diabetics represented 27% (n = 19) and 13% (n=9) of the patient population, respectively. Results: Complete/partial union was seen in 89% of all joints (113/127) and 93% of midfoot joints (98/106). Chopart joints had a significantly lower healing rate (15/21; 71%) compared to midfoot joints (p = 0.013) and TMT joints in isolation (86/91; 95%) (p = 0.006). Neuropathy and smoking had no effect on healing but diabetes did (p = 0.004). Joints requiring bone grafting had a worse healing rate (38/49; 76%) (p = 0.002). For all joints, post-operative VAS scores were significantly lower than pre-operative (p < 0.00001). Midfoot and Chopart pre-operative pain scores did not differ (p= 0.30), but differed post-operatively (p = 0.003). Midfoot joints had significantly lower pain scores post-operatively than pre-operatively (p < 0.00001). No such significance existed in Chopart joints (p = 0.070). Conclusion: Isolated nitinol staples are a viable option for midfoot arthrodesis, especially TMT joints, and offer significant pain improvement. Staples are lower profile, decreasing hardware irritation and potential secondary surgeries, and ease of use makes insertion efficient and reproducible. They offer the benefit of continuous compression of the fusion site, and are rigid enough to maintain reduction. Chopart joints, however, may require a more rigid fixation than nitinol staples can provide, given the lower healing rate. Caution should be exercised in diabetics and joints that may require bone grafting.

Integrity of the First Metatarsal Head Vascularization and Soft-Tissue Envelope Following Minimally Invasive Chevron Osteotomy for Hallux Valgus (HV) Deformity: A Micro-CT and Anatomical Assessment

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: Minimally invasive surgery (MIS) Chevron-osteotomy for HV treatment offers a surgical alternative to open surgery with minimal surgical dissection and a hypothetical decreased risk for soft-tissue complications. During this procedure, there is a concern regarding the injury to the blood supply of the 1st-metatarsal-head. The objective of this study was to assess the incidence of injuries: (1) to the soft-tissue envelope around the first metatarsal head complex and, (2) to the blood supply of the first metatarsal head and also by using Micro-CT, (3) looking for safe zones close to the first metatarsal head to perform MIS Chevron osteotomy. We hypothesized that the MIS Chevron-type osteotomy procedure would preserve the soft-tissue envelope of the first-metatarsal-head complex and the blood supply of the 1st-metatarsal-head. Methods: Sixteen HV deformity cadaveric specimens were used to perform MIS Chevron-type osteotomy of the first metatarsal head. Anatomical dissection of all specimens was then performed to assess macroscopic injury to the first metatarsal head complex soft-tissue structures, including Extensor Hallucis Longus (EHL) tendon, Extensor Hallucis Brevis (EHB) tendon, Flexor Hallucis Longus (FHL) tendon, Flexor Hallucis Brevis (FHB) tendon, Abductor Hallucis tendon, Adductor Hallucis tendon, Sesamoid complex, Dorsolateral and Dorsomedial digital branches of the first toe and the Dorsomedial digital branch to the second. Macroscopic injuries were classified using a calibrated digital caliper. Any chondral damage to the first metatarsal head was quantified in mm². To assess the amount of first metatarsal head blood supply, specimens were perfused with 200 ml of a low viscosity radiopaque polymer, MV 117 (Flowtech), preoperatively, followed by Micro-CT assessment. Descriptive statistics and percentages were utilized for categorical data. Results: We did not find injuries in the EHL, EHB, FHL, Abductor-Hallucis, and Adductor-Hallucis tendons. We found a 2mm injury in the FHB tendon in one specimen. No injuries were found in the Dorsomedial and Dorsolateral nerves of the first-toe, the Dorsomedial-nerve of the second-toe, and Medial branch of the dorsomedial-nerve of the first-toe. In 3 cases, we found an injury on first-metatarsal-head (1mm) due to the passage of the K-wire and, in 1 case, due to the inadvertent passage of the drill (4.41mm). Macroscopically and using Micro-CT, we did not observe injuries in the First-Dorsal-Metatarsal-Artery (FDMA), Lateral-Dorsal-Branch of FDMA, and Plantar-Metatarsal-Artery. Micro-CT helped estimate a safe distance to finish the proximal exit of Chevron-osteotomy (25mm from the most distal point of the first metatarsal head). Conclusion: In this study, the minimally invasive Chevron osteotomy for treating HV seems to be a technically safe procedure, presenting a low rate of iatrogenic injuries with a low degree of severity. In addition, using Micro-CT promoted a better visualization of the microvasculature that nourishes the first metatarsal head. We observed that a proximal distance of 25 mm from the most distal part of the first metatarsal head could be a safe place to finalize the Chevron osteotomy, minimizing the risk of injury to the blood supply of the first metatarsal head.

Possibilities of Using Laser Radiation in Vitreoretinal Surgery

Currently, laser technologies are widely used in the treatment of diseases of the eye and its accessory apparatus. Basically, they are used in oculoplastic surgery during operations on the accessory apparatus of the eye, in refractive and corneal surgery, laser support for ultrasound cataract surgery, laser treatment of glaucoma, laser coagulation of the retina, thermotherapy of choroidal formations. In the 21st century, Nd: YAG laser treatment of floating opacities in the vitreous body began to be actively popularized with mixed results. In vitreoretinal surgery, which is improving every decade, laser technology remains at the level of the 20th century. In endovitreal surgery, the laser is still used only for endolaser coagulation of the retina, despite the fact that there is a huge potential for using lasers as a “laser scalpel” for removing the vitreous, precision removal of a retinal tear, epiretinal fibrosis, precision retinotomy, and choroidotomy. In this regard, it is necessary to search for the most suitable laser radiation, which will make it possible to carry out thin cuts on the retina and choroid with high accuracy, minimal damage to the surrounding tissues, and a sufficient degree of coagulation to prevent hemorrhages. This laser will allow for surgical interventions in the posterior eye segment with a lower risk of intra- and postoperative complications, as well as better anatomical and functional results. With further development, this new approach to laser ablation may become an alternative to mechanical instruments for surgical dissection and removal of pathological tissue from the surface of the retina.

A Novel Isobaric (Gas-Less) Laparoscopic Surgery Device.

Laparoscopic Surgery is performed using carbon dioxide gas insufflated into the abdominal cavity to create a space for endoscopic visualization. During a laparoscopic surgical dissection plume is formed from electrocautery dissection. This plume contains viruses and sometimes COVID-19 viruses. The plume obscures the visual field. The unfiltered plume release is dangerous to surgeons, nurses, and patients. The loss of visualization during carbon dioxide release delays surgery. The use of carbon dioxide insufflated gas can have side effects such as C02 embolus, pain from diaphragmatic stretching, physiological complications such as respiratory infections and renal problems. The release of carbon dioxide gas into the atmosphere, unfiltered is significant. This accounts for 7% of greenhouse gases globally. This percentage is rising due to expansion of minimally invasive surgery. The proposed system for gasless surgery was designed by algorithms of tensegrity and geodesic dome pressures. 100 simulator studies were performed to develop the device to elevate the abdominal wall to create a gas free (isobaric) space for Laparoscopic Surgery. After design freeze, 4 animal studies were performed using ethical research guidelines at Amsterdam Medical Centre Research Department, Netherlands. 3 cadaveric studies were performed using Ethical guidelines at Hackensack University Medical Centre, New Jersey, USA, to evaluate the device in a human setting. These devices for Laparoscopic Surgery, Robotic Surgery, and Hand Assisted Laparoscopic Surgery (HALS) successfully proved that a superior intra-abdominal space can be created without carbon dioxide insufflation. The devices are patented in USA and Europe.

Anatomy of the Facial Glideplanes, Deep Plane Spaces, and Ligaments: Implications for Surgical and Nonsurgical Lifting Procedures.

The soft-tissue glideplanes of the face are functionally important and have a role in facial rejuvenation surgery. The aim of this study was to improve understanding of soft-tissue mobility of the face and its effect on the redraping of tissues involved in face lifting. The consequences of no-release and extensive-release lifting were analyzed to explain the difference in efficacy and potential longevity between these 2 contrasting philosophies. Preliminary dissections and macrosectioning were followed by a definitive series of standardized layered dissections on 50 cadaver heads, along with histologic analysis, sheet plastination, and mechanical testing. The previously described spaces are potential surgical dissection planes deep to the superficial fascia layer. The classically described retaining ligaments are local reinforcements of a system of small retaining fibers (retinacula cutis and deep retinacula fibers) that provide support to the soft tissues of the face and neck against gravitational sagging while allowing certain mobility. This mobility is used when mobile tissues are lifted without surgical release. However, the process of dragging up these fibers results in a loss of their previous antigravitational, supportive orientation. No-release lifting techniques, such as thread lifts and minimal-invasive face lifts, tighten tissue laxity with a change of the gravity-opposing tissue architecture, placing the weight of the flap solely on the fixation, which limits longevity of the lift. The alternative-full release with redraping-enables reattachment of the flap to a higher position, with preservation of the original deep fascial architecture with its antigravity orientation and natural mobility, conceivably improving the longevity of the lift.

Determinants of Perioperative Complications in Day-Surgery for Endometriosis: A Retrospective Cohort

ObjectivesEndometriosis is a common gynaecologic disease for which surgery is often required. Our objective was to evaluate the potential determinants of perioperative complications in day-surgeries for endometriosis. MethodsWe conducted a retrospective cohort study of patients undergoing day-surgeries for endometriosis using Canadian administrative data from between 2015 and 2019. A multilevel logistic model with a random intercept at the centre level was created to assess the association between potential determinants, including age, site(s) of endometriosis lesion, centre-volume, surgical intervention, and a composite outcome of complications or specific complications. ResultsWe observed a higher risk of complications associated with greater age (40–44 vs. 20–24 years, adjusted odds ratio [aOR] 1.58; 95% CI 1.26–1.98); hysterectomies (aOR 2.29; 95% CI 1.73–3.06) compared with minor conservative surgery; lesions of the bowel or urinary tract system (aOR 1.54; 95% CI 1.16–2.06), and extra-pelvic sites of endometriosis (aOR 1.24; 95% CI 1.07–1.52) compared with endometriosis of the uterus; and with comorbidities (aOR 1.59; 95% CI 1.09–2.32). Endometriosis lesions to the bowel and urinary tract system and to extra-pelvic sites (compared with no endometriosis at the site) were associated with a greater risk of accidental damages (aOR 1.84; 95% CI 1.43–2.37) and urinary system complications (aOR 1.75; 95% CI 1.24–2.48), respectively. Among patients undergoing hysterectomies compared with those undergoing minor conservative surgery, infectious complications (aOR 8.56; 95% CI 4.70–15.59) and accidental damages (aOR 2.31; 95% CI 1.70–3.14) were more frequent. ConclusionsComplications in day-surgeries for endometriosis are more frequent with older age, hysterectomy, comorbidities, and endometriosis of the bowel, urinary tract system, and extra-pelvic locations. More extensive disease is associated with more extensive surgical dissection and a higher risk of complications.

Поздний синдром капсульного блока с гиперметропическим сдвигом. Клинический случай

Capsular block syndrome (CBS) is one of complications of modern cataract surgery technique, due to restriction of fluid passage from the capsular bag, which in different terms of postoperative period of cataract phacoemulsification may lead to reduction of both anatomical and functional results of surgery. The treatment of choice of the capsular block syndrome, especially during early postoperative period, is YAG laser dissection of the posterior capsule, which in most cases allows restoring transparency and refraction. In cases like lactocrumenasia (a variant of late CBS) it is not always possible to visualize the posterior capsule and evacuate the contents, therefore, the treatment of choice can be surgical dissection and aspiration of the contents. However, according to the literature, there is a possibility of infection of isolated capsule contents which obliges to correctly and carefully determine the surgical tactics in such cases. This article presents a rare case of late postoperative capsular block syndrome with hyperopic shift in a patient with proliferative diabetic retinopathy and silicone tamponade of the vitreous cavity. Key words: capsular block syndrome; hyperopic shift; cataract phacoemulsification.

370. TRANSMEDIASTINAL ESOPHAGECTOMY IS USEFUL FOR ESOPHAGOGASTRIC JUNCTION CANCER

Abstract Background The extent of surgical resection and lymph node dissection in esophagogastric junction cancer depends on the localization of the tumor center and the length of esophageal invasion. We developed Robot assisted-transmediastinal esophagectomy (TME) and have been applied for thoracic esophageal cancer. Since 2018, we also applied TME for esophagogastric junction (EGJ) cancer with esophageal involvement according to our determined indications, and examined its safety and usefulness. Methods Our indication of esophagetomy for EGJ cancer is, i) squamous cell carcinoma, ii) differentiated adenocarcinoma with≧3 cm esophageal involvement, iii) poorly differentiated with≧2 cm. Since 2018, we applied TME for all of these cases. Our operation procedure is following; upper thoracic paraesophageal LNs and recurrent nerve LNs are dissected by left-side cervical mediastinoscopic approach. Lower mediastinal LN is dissected by laparoscopic approach. Subcarinal LNs and main bronchus LNs are dissected by transhiatal robotic approach. When robot is not used, these LNs are dissected mediastionscopically. Reconstruction is done by gastric tube through posterior mediastinal route. Results Between January 2018 and March 2023, 36 patients was performed TME for EGJ cancer. In these, robot was used in 24 patients. Median operation time and amount of blood loss were 429 minutes and 170 mL. Pathological metastasis of thoracic paratracheal LNs; right recurrent nerve LNs, left recurrent nerve LNs and tracheobronchial LNs was detected in 2(5.5%), 1(2.7%) and 1(2.7%) patients, respectively. Anastomotic leakage was occurred in 2(5.5%) patients, but recovered conservatively. Recurrent laryngeal nerve (RLN) palsy severe more than Clavien-Dindo (CD) grade III was not occurred. Postoperative complications≧C-D IIIb was occurred in 1(2.7%) patient. Conclusion TME for EGJ cancer seems to be safe, especially can avoid intra-mediastinal anastomosis and severe complication associated with leakage. It might be more widely accepted when RLN palsy could be reduced. Recuurent nerve LNs dissection is main cause of RLN palsy, and not recommended in the algorism of LN dissection for EGJ cancer because the frequency of metastasis is low, so TME without recurrent nerve LNs dissection could be the option for EGJ cancer.

Projection of realistic three-dimensional photogrammetry models using stereoscopic display: A technical note.

The 3D stereoscopic technique consists in providing the illusional perception of depth of a given object using two different images mimicking how the right and left eyes capture the object. Both images are slightly different and when overlapped gives a three-dimensional (3D) experience. Considering the limitations for establishing surgical laboratories and dissections courses in some educational institutions, techniques such as stereoscopy and photogrammetry seem to play an important role in neuroanatomy and neurosurgical education. The aim of this study was to describe how to combine and set up realistic models acquired with photogrammetry scans in 3D stereoscopic projections. Three donors, one dry skull, embalmed brain and head, were scanned using photogrammetry. The software used for displaying the final realistic 3D models (Blender, Amsterdam, the Netherlands) is a free software and allows stereoscopic projection without compromising the interactivity of each model. By default, the model was exported and immediately displayed as a red cyan 3D mode. The 3D projector used in the manuscript required a side-by-side 3D mode which was set up with simple commands on the software. The final stereoscopy projection offered depth perception and a visualization in 360° of each donor; this perception was noted especially when visualizing donors with different cavities and fossae. The combination of 3D techniques is of paramount importance for neuroanatomy education. Stereoscopic projections could provide a valuable tool for neuroanatomy instruction directed at clinical trainees and could be especially useful when access to laboratory-based learning is limited.

Comparison between Tonsillectomy by Coblation, Bipolar and Surgical Dissection

Abstract Background Tonsillectomy is one of the most common paediatric surgical procedures performed worldwide. Although it is one of the most widely performed procedures in otorhinolaryngology, none of the commonly used techniques for tonsillectomy is considered optimal till now. Objective To compare coblation, bipolar diathermy, and surgical dissection approaches for tonsillectomy in terms of operative time, surgical blood loss, postoperative pain and the incidence of postoperative complications. Methods A systematic review and meta-analysis in accordance to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) statement. Guidelines and an electronic search of information was conducted to identify studies that compare between coblation, cold dissection and bipolar diathermy techniques. Results This study showed that bipolar diathermy tonsillectomy was the lowest risk of primary bleeding followed by coblation then cold dissection tonsillectomy but with insignificant difference. Coblation technique was the highest secondary bleeding risk followed by cold dissection and the lowest risk was figured in bipolar diathermy procedure also the difference did not reach statistical significance. Coblation tonsillectomy was the best technique regarding blood loss and operative time with significant difference in the comparison with cold dissection and insignificant in the comparison with bipolar diathermy. Because of using a different postoperative pain measures in the studies we could not pool its data, but the majority of studies showed that coblation technique was better as regard postoperative pain than cold dissection and bipolar diathermy. While there was no significant difference between cold dissection and bipolar diathermy in the most studies Conclusion Overall, bipolar diathermy procedure for tonsillectomy was considered the best technique regarding primary and secondary bleeding outcomes, but the difference did not reach statistical significance. Coblation procedure for tonsillectomy was considered the best technique regarding intraoperative blood loss with significant difference except in comparison between bipolar diathermy and coblation the difference was not significant. Coblation technique also considered the best one regarding operative time with significant difference in direct comparison between coblation and cold, and insignificant in other comparisons. By systematic review on 21 studies coblation technique shows less postoperative pain than cold dissection and bipolar diathermy in the majority of studies comparing coblation with every technique. And there was no significant difference between studies compared cold dissection with bipolar diathermy regarding postoperative pain.

Lymph Node Metastases from Non-Melanoma Skin Cancer of the Head and Neck.

Non-melanoma skin cancer (NMSC) represents the most common malignancy in the world, comprising exceedingly common lesions such as basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) and rare lesions such as Merkel cell carcinoma. Risk factors are widely recognized and include ultraviolet (UV) light exposure, radiation exposure, immunosuppression, and many others. As a whole, survival and functional outcomes are favorable, but each histopathological subtype of NMSC behaves differently. Treatment regimens for the primary site usually include wide surgical excision and neck dissection in cases of clinically involved metastatic lymph nodes. The elective management of draining nodal basins, however, is a contested topic. Nearly all subtypes, excluding BCC, have a significant risk of lymphatic metastases, and have been studied with regard to sentinel lymph node biopsy (SLNB) and elective neck dissection. To date, no studies have definitively established a true single standard of care, as exists for melanoma, for any of the NMSCs. As a result, the authors have sought to summarize the current literature and identify indications and management options for the management of the cervical lymphatics for each major subtype of NMSC. Further research remains critically necessary in order to develop complete treatment algorithms.

Pediatric intraspinal arachnoid cyst: successful endoscopic fenestration. Illustrative case.

Intradural spinal arachnoid cysts (SACs) are a rare cause of spinal cord compression. Treatment is centered on decompression of the spinal cord via laminectomy or laminoplasty followed by resection or fenestration of the cyst. Although laminectomy or laminoplasty access may be needed to achieve the desired result, either procedure can be associated with more extensive surgical dissections and long-term spinal stability concerns, including postsurgical kyphosis. The authors present a case of a cervical intradural SAC in a 4-month-old girl presenting with symptomatic compression. The patient was treated by laminotomy and endoscopic fenestration of the SAC with resolution of symptoms and no disease progression 10 months postoperatively, when the patient was 14 months old. Microsurgical endoscopic fenestration of an intradural SAC can provide a less invasive means of treatment while avoiding the risks associated with more invasive approaches.

The efficacy in shoulder range of motion of a snapping manual maneuver added to a standardized exercise protocol in axillary web syndrome: a randomized controlled trial

Purpose Axillary Web Syndrome (AWS) is a common sequela after surgical axillary lymph node dissection (ALND) often manifesting with reduced range of motion (ROM) of the limb, which requires rehabilitation. Notwithstanding, a standardized rehabilitation protocol is currently lacking in clinical practice. Our primary objective was therefore to evaluate the effectiveness of the use of a snapping manual maneuver (SMM, used in our clinical practice) to increase ROM during abduction (ABD) when compared with a standardized stretching exercise (SSE) protocol. A three-year follow-up of the enrolled patients was also carried out to determine the incidence of Breast Cancer-Related Lymphedema (BCRL). Materials and methods Between July 2013 and January 2019, we conducted a single-blinded randomized clinical trial. A total of 60 patients, who underwent ALND in our hospital, came to our clinic under medical advice or on voluntary access and reported AWS symptoms. The patients were randomly assigned into two equally divided groups. The treatment of group one consists in the execution of a supervised SSEs protocol, while group two additionally received a manual snapping maneuver. Patients of both groups received two treatment sessions within two weeks. At the end of the session, they were asked to continue the exercises autonomously on a daily basis, three times per day, for one month. Results There were no statically significant differences in ROM at our one-month follow-up and the incidence of BCRL was equally distributed after three years. Conclusions The use of the manual snapping maneuver in addition to stretching once per week for two weeks does not appear to improve the outcome of the patients in comparison with stretching alone and does not appear to be related to lymphedema in our 3 years follow-up.

Robot-assisted Laparoscopic Excision of Abdominal Wall Endometrioma Utilizing Intraoperative Ultrasound and Transabdominal Needle Placement

In patients with endometriosis, extra pelvic endometriosis is estimated to have an incidence of 11% and a rare subset of extra pelvic lesions include abdominal wall endometriosis with an incidence of 0.03-3.5%1,3. Evaluation for and surgical management of abdominal wall endometriosis is an essential skillset for the advanced gynecologic surgeon. In this video, we demonstrate a surgical technique for robot-assisted laparoscopic excision of abdominal wall endometriosis with intraoperative ultrasound-guided needle placement. Description and demonstration of surgical technique. Patient with previous history of 2 cesarean sections and right lower quadrant cyclic abdominal wall pain. Tertiary care, academic center INTERVENTIONS: Intraoperative ultrasound-guided needle placement to map location and boundaries of the lesion followed by minimally invasive resection of the lesion with the intermittent advancement and withdrawal of needles to confirm clear margins. Minimally invasive resection of abdominal wall endometriosis using intraoperative ultrasound guided needle placement is an effective technique to guide surgical dissection and allow for clear surgical margins and successful treatment of this rare condition.

The Correlation of Thyroid Hormone Levels and Anti-Thyroidal Drugs on Thyroid Size, Weight, and Ease of Surgical Dissection for Thyroidectomy for Graves' Disease.

Patients with Graves' Disease often have a larger thyroid size than patients without thyroid disease. These patients also have elevated T3 and T4 with decreased TSH. We evaluate whether these thyroid labs, the use of antithyroid agents, or the size of a thyroid on ultrasound, correlate with the pathological size of a thyroid in patients who undergo total thyroidectomy for Graves' Disease. We further determine whether these parameters affect perioperative complications. A retrospective review of patients undergoing total thyroidectomy for Graves' Disease was performed from January 2004 to December 2016 in a single institution. 392 patients were included in the study. Univariate analyses were performed to compare thyroid size on US and pathology as well as weight to preoperative thyroid hormone values and medical comorbidities. Spearman rank correlation and ANOVA were used to identify factors associated with thyroid weight, total pathology size, and differences in size. Multivariate analysis was also performed to evaluate for correlation between thyroid function and perioperative complications. We found that elevated pre-operative T3 levels were associated with larger pathologic size (P = .027) and a greater difference in pathology vs. US thyroid volumes (P = .005), but not increased thyroid weight (P = .286). No significant differences were found for thyroid weight, pathology size, or difference in size for TSH, T4, or any specific preoperative ATD given. Only postoperative calcium levels were found to be statistically significant for TSH < 0.27 (P = .024) for peri-operative complications. These findings may allow for more accurate preoperative planning and intraoperative expectations in patients with Graves' Disease.

Recognition of the membrane anatomy-based laparoscopic assisted right hemicolectomy

Although it has become a consensus in the field of colorectal surgery to perform radical tumor treatment and functional protection under the minimally invasive concept, there exist many controversies during clinical practice, including the concept of embryonic development of abdominal organs and membrane anatomy, the principle of membrane anatomy related to right hemicolectomy, D3 resection, and identification of the inner boundary. In this paper, we analyzed recently reported literature with high-level evidence and clinical data from the author's hospital to recognize and review the membrane anatomy-based laparoscopic assisted right hemicolectomy for right colon cancer, emphasizing the importance of priority of surgical dissection planes, vascular orientation, and full understanding of the fascial space, and proposing that the surgical planes should be dissected in the parietal-prerenal fascial space, and the incision should be 1 cm from the descending and horizontal part of the duodenum. The surgery should be performed according to a standard procedure with strict quality control. To identify the resection range of D3 dissection, it is necessary to establish a clinical, imaging, and pathological evaluation model for multiple factors or to apply indocyanine green and nano-carbon lymphatic tracer intraoperatively to guide precise lymph node dissection. We expect more high-level evidence of evidence-based medicine to prove the inner boundary of laparoscopic assisted radical right colectomy and a more rigorous consensus to be established.

Indocyanine green (ICG) angiography-guided thyroidectomy: description of surgical technique.

Postoperative hypoparathyroidism is the most common complication after total thyroidectomy and, when becomes permanent, lead to a myriad of clinical symptoms, long-term need of calcium and vitamin D supplementation and negative impact on the patient's health-related quality of life. Any surgical innovation that could reduce complications and improve outcomes of patients undergoing total thyroidectomy deserves to be considered. Angiography-Guided Thyroidectomy has been proposed as a modification of the standard technique of thyroidectomy aimed to identifying the vascular pattern of the parathyroid glands to maximize efforts for preserving functioning glands at the time of operation. Our aim is to provide a technical description of this procedure based on the use of indocyanine green (ICG) angiography to standardize this technique. The surgical steps that are followed during a total thyroidectomy are modified due to previous visualization of the feeding vessels of the parathyroid glands according to fluorescence of the vascular mapping obtained by ICG angiography prior to thyroidectomy. The first step is to perform an ICG angiography to assess anatomical features of the feeding vasculature of the parathyroid glands, which allows precise surgical dissection for preservation of the glands. Once the viability of the parathyroids has been evaluated angiographically, thyroidectomy is performed in a second step. ICG angiography-guided thyroidectomy may be effective to preserve the largest number of better perfused parathyroid glands, which would contribute to reduce the risk of postoperative and permanent hypoparathyroidism. It can be successfully and safely implemented in thyroid surgery and standardization of the technique is necessary to homogenize this procedure in the future, allowing a better comparation of the results to be published.

Surgical anatomy of the clitoris and surrounding vulvar structures

Injury to the clitoris and its associated nerve supply has the potential to adversely impact sexual arousal and sexual response. Strategies to avoid such injuries during vulvar procedures are not well described, in part, because of the limited understanding of clitoral anatomy. In particular, resources demonstrating methods of periclitoral surgical dissection are rare. To overcome this gap, we created a surgical video tutorial describing the anatomy of the clitoris and surrounding structures using cadaveric specimens. Gross dissections were performed to examine the anatomic relationships of the clitoris, the dorsal nerve of the clitoris, and the autonomic nerve supply. Techniques to identify and follow the path of the dorsal nerve of the clitoris and strategies to avoid nerve injury when dissecting near the clitoris are highlighted. Enhanced awareness of this anatomy will improve our ability to understand and prevent disruption of the clitoral nerve supply and will improve our ability to appropriately counsel patients on the risks of vulvar surgery.

Giant Lipoma of the Hand: An Exceedingly Rare Condition!

Lipomas are the most common benign form of soft tissue tumor in the body. Although they are commonly found on the upper extremity, their occurrence in the hand is rare. Giant lipomas of the hand, defined as &gt;5 cm in diameter, are extremely rare. This manuscript reports a very rare case of giant lipoma on the palmar side of the hand in order to study the diagnostic, theurapeutic and prognostic aspects. A 61 year-old female had a large asymptomatic thenar swelling since 10 years. The clinical examination showed a subcutaneous tumor spreading the 1st commissure and making opposition of the thumb very limited. There were no inflammatory signs and no pain. The patient didn’t report any sensory deficit and the neurological examination was normal. The standard X-ray showed a tissue image without bone lesions. MRI demonstrated a large, well-limited T1, T2 hypersignal tissue formation, which developed in the subcutaneous fat of the first commissure, insinuated itself in front of the last three metacarpals, and included the deep and superficial flexor tendons. The patient was operated on under local anesthesia and pneumatic tourniquet at the root of the limb. The approach allowed a satisfactory exposure of the entire palm of the hand and revealed a lipomatous mass, encapsulated, pushing back the vascular and neural pedicles of the long fingers without invading them and remaining in front of the flexor tendons. The tumor was carefully dissected, which allowed it to be removed totally. Histology confirmed the diagnosis of benign lipoma. Complete recovery was achieved without any sign of recurrence during a follow up period of 5 years. Lipomas of the hand represent a rare benign tumor pathology; giant lipomas represent an exceedingly rare condition. The proximity of the relationships with the vascular and neural structures must lead to the greatest caution during surgical dissection. Only anatomopathological examinations confirm the histological nature of the lesion.

Tissue Acceleration as a Novel Metric for Surgical Performance During Carotid Endarterectomy.

Gentle tissue handling to avoid excessive motion of affected fragile vessels during surgical dissection is essential for both surgeon proficiency and patient safety during carotid endarterectomy (CEA). However, a void remains in the quantification of these aspects during surgery. The video-based measurement of tissue acceleration is presented as a novel metric for the objective assessment of surgical performance. This study aimed to evaluate whether such metrics correlate with both surgeons' skill proficiency and adverse events during CEA. In a retrospective study including 117 patients who underwent CEA, acceleration of the carotid artery was measured during exposure through a video-based analysis. Tissue acceleration values and threshold violation error frequencies were analyzed and compared among the surgeon groups with different surgical experience (3 groups: novice , intermediate , and expert ). Multiple patient-related variables, surgeon groups, and video-based surgical performance parameters were compared between the patients with and without adverse events during CEA. Eleven patients (9.4%) experienced adverse events after CEA, and the rate of adverse events significantly correlated with the surgeon group. The mean maximum tissue acceleration and number of errors during surgical tasks significantly decreased from novice, to intermediate, to expert surgeons, and stepwise discriminant analysis showed that the combined use of surgical performance factors could accurately discriminate between surgeon groups. The multivariate logistic regression analysis revealed that the number of errors and vulnerable carotid plaques were associated with adverse events. Tissue acceleration profiles can be a novel metric for the objective assessment of surgical performance and the prediction of adverse events during surgery. Thus, this concept can be introduced into futuristic computer-aided surgeries for both surgical education and patient safety.