Surgical Point Research Articles

Variations in the Axillary Artery Branching Pattern

Variations in axillary artery branching pattern can lead to iatrogenic injuries during invasive procedures. Knowledge of the same is critical to prevent such events. Multiple bilateral variations were observed in the branching pattern of axillary artery. These variations were noted in a female cadaver, during routine undergraduate dissection in September 2019 in Lady Hardinge Medical College, New Delhi. On the left side, an anomalous branch running with the medial pectoral nerve was found. A common stem arising from the 2nd part of left axillary artery divided to give the lateral thoracic artery, the subscapular artery and an alar artery. Another alar branch arose from the left subscapular artery before it bifurcated into thoraco-dorsal and circumflex scapular arteries. The right axillary artery gave an aberrant branch proximal to the lateral thoracic artery. A common trunk arising from the 2nd part of right axillary branched out to give the posterior circumflex humeral artery, the subscapular artery and an alar artery. The brachial artery divided 13.5 cm proximal to the intercondylar line of humerus on the left and 14.4 cm on the right side. On both sides, the ulnar artery arose proximally and the radial and common inter-osseous arteries continued as a common trunk and divided distally. This case study reports multiple bilateral axillary artery anomalies and complements to the existing knowledge of vascular anomalies. Comprehensive knowledge of these variations is essential from anatomical, radiological and surgical point of view. During surgeries involving axillary and pectoral group of lymph nodes, such variations should be kept in mind.

“POTENTIALLY SURVIVABLE” CASUALTIES — RESERVE TO REDUCE PRE-HOSPITAL LETHAILITY IN INJURIES AND TRAUMAS

Battlefield lethality remains the most underexplored problem from the surgical point of view. 540 battle­field fatalities during the military operation in the North Caucasus region of Russia (1994–1996) were ana­lyzed. It was found that 25.4% of all “Killed In Action” refer to the group of potentially survivable. Common causes of combat death in this group were prolonged hemorrhage (78.1%), tension pneumothorax (19.0%), and hemopneumothorax (2.9%). Reducing mortality can be attained due to introduction of new means of control for life-threatening consequences of injuries, improving tactical evacuation, as well as training mili­tary personnel in providing combat lifesaver care.

ACT-22 CLINICAL RESULT AND CONSIDERATION OF 70 CASES OF INSULAR GLIOMA

Our policy for insular glioma has achieved more than 90% removal. The policy influence grade 2 to postpone farther treatment and grade 3 to extend prognosis. In this study, we analyzed our clinical data to be sure how this policy effect to insular glioma. First-onset tumor since 2006 to 2015 were collected and following parameters were analyzed retrospectively, such as the tumor, extension, surgical removal rate, complications, pathological and genomic diagnosis. Of all 70 cases, the average age was 41 years old (24–76). The pathological diagnosis and number of patients were DAmt 20, DAwt 1, AAmt 8, AAwt 5, AO 5, O 18. PFS of each pathological grade(2,3,4) were 55,5m, 42,6m and 4,7m, OS were nr, nr, 32,8 months. 57 cases of IDHmt showed 60,2m of PFS and n.r of OS. 10 cases of IDHwt showed 19,9m PFS and 35,8m OS. The average and median removal rate were 91.4% and 95%. The number of complication case were mild 9 and moderate 2 at 3 months after surgery. The invasion pattern from temporal stem showed that frontal base invasion cases was resulted as poor prognosis comparing with temporal or parietal extension. Number of patients with IDHwt, Oligodedroglial tumor and GBM were relatively low. Surgical complications are mainly caused in the first half of the proficiency process, 15% had paralysis due to LSA infarction. Most of grade 2 cases were treated without post-operative treatment and the prognosis was almost same as grade 3 cases which were treated by chemo and radiation therapy such as 55m, 43m of PFS and n.r of OS. AA wt and GBM showed almost same OS of 32m.We have reconsidered a new classification based on temporal stem extension from surgical point of view. Insular glioma is somewhat different from the other location glioma.

The inguinal region revisited: the surgical point of view

PurposeInguinodynia or chronic post-herniorrhaphy pain, defined as pain lasting longer than 3 months after open inguinal hernia repair, has become the most important complication after inguinal surgery and therefore compromises the patient´s quality of life. A major reason for inguinodynia might be the lack of neuroanatomical knowledge and suboptimal “management” of the nerves during surgery.MethodsWe present a detailed neuroanatomic mapping of the inguinal region by dissection including the most important surgical landmarks with all nerves confirmed by immunohistochemistry, ultrasound guided visualization of the iliohypogastric, ilio-inguinal, and genital branch of the genitofemoral nerve, and a practical (preoperative) algorithm for clinical management.ResultsSurgically and ultrasonographically relevant structures (“landmarks”) in open hernia repair are the anterior–superior iliac spine, pubic tubercle, Camper´s fascia (superficial layer of the superficial abdominal fascia), External oblique aponeurosis, Internal oblique muscle, Transversus abdominis muscle, superficial inguinal ring, external spermatic fascia, cremasteric fascia with cremaster muscle fibers, internal spermatic fascia, cremasteric vein (=external spermatic vein = “blue line”), ductus deferens, pampiniform plexus, inguinal ligament and the inferior epigastric vessels.ConclusionA detailed understanding of inguinal anatomy is an indispensable basic requirement for all surgeons to perform inguinal ultrasonography as well as open inguinal hernia repair, avoiding complications, especially postoperative inguinodynia.

Thoracoscopic en bloc resection of left upper lobe lung cancer

In this video tutorial we demonstrate our procedure for en bloc resection of the left upper lobe and the regional lymph nodes via video-assisted thoracic surgery in patients with primary lung cancer and outline some key surgical points. First, the operation should start with dissection of the posterior portion of the hilar and lower paratracheal nodes, which will provide excellent visualization of the left recurrent laryngeal nerve and also facilitate dissection of the subaortic and para-aortic (aorto-pulmonary) nodes. Second, the lower paratracheal nodes and aorto-pulmonary nodes should be mobilized together with their dominant lymphatic drainage pathways from the left upper lobe. During this procedure, care must be taken not to divide the peribronchial lymphatic pathway toward the lower paratracheal nodes or the subpleural lymphatic pathway toward the aorto-pulmonary nodes. By following these guidelines, the left upper lobe and the regional lymph nodes can be resected en bloc without any division of their lymphatic connection. We believe that this procedure will help prevent pleural dissemination as well as prevent the surgeon's missing any metastatic lymph nodes.

6-mm-short and 11-mm-long implants compared in the full-arch rehabilitation of the edentulous mandible: A 3-year multicenter randomized controlled trial.

The aim of this multicenter parallel-group randomized controlled trial is to compare 6-mm-short with 11-mm-long implants in the rehabilitation of totally edentulous mandible in a completely comparable clinical situation, from anatomical, surgical, and prosthetic point of view. Thirty patients were selected in three study centers to receive a fixed full-arch mandibular rehabilitation supported by five inter-foraminal implants. Patients were randomly allocated, at the time of surgery, half to the test group (6-mm-long implants) and half to the control group (11-mm-long implants). No bone augmentation procedure was performed. After 3months, a screw-retained full-arch prosthesis with distal cantilevers was positioned (baseline). Peri-implant marginal bone level change (MBLc), implant and prosthesis survival rate, and biological/technical complications were evaluated after 1 and 3years. Thirty subjects (150 implants) were evaluated after 1year and 28 (140 implants) after 3years. No implant or prosthesis loss occurred. No significant inter-group difference for biological/technical complications was registered. No statistically significant (p>.025) intra-group or inter-group difference in the mean MBLc values was registered. The mean MBLc was 0.01±0.19mm and -0.04±0.21mm at 1year, and -0.10±0.24mm and 0.02±0.25mm at 3years (test and control groups, respectively). 6-mm-short implants may be a reliable option when used in the rehabilitation of total edentulous mandibles. These results need to be confirmed by longer follow-up data from well-designed randomized controlled clinical trials.

Focus on Very Late Hepatocellular Carcinoma Recurring After Liver Transplantation: A Case Report and Literature Review

Hepatocellular carcinoma (HCC) recurring after liver transplantation (LT) is a major clinical concern, occurring in up to 20% and being the most frequent cause of death in this setting. Usually recurrence occurs within the first 2 years, whereas late and very late recurrences are rare. We report a 71-year-old woman with HCC recurrence after 25 years from LT, an event never reported before. Diagnosis was achieved with a progressive increase of alpha-fetoprotein (AFP) followed by a computed tomography scan, showing a mediastinal, upper diaphragmatic, right paracaval mass of 5 cm in size. The lesion was treated with a surgical approach involving a multidisciplinary team including hepatobiliary, thoracic, and cardiovascular surgeons. A sternotomy and mass removal was performed without the need of an extracorporeal bypass. A complete resection of the tumor was achieved, with a drop in AFP and without signs of recurrence after 1-year follow up. In conclusion, the possibility of late HCC recurrences after LT, despite being rare, underlines the need of a standardized, cost-benefit, optimal strategy of a long-term surveillance. From a surgical point of view, our case is unusual for the site and the character of the lesion, and for the absence of the need of an extracorporeal bypass during the operation.

Laparoscopic resection of gastric GISTs. Where do we stand now? A single-centered experience

Introduction. Gastrointestinal stromal tumors (GISTs) represent a rare type of gastrointestinal neoplasms. Resection with negative margins has been established as a mainstay treatment, but laparoscopic resections are still open to debate. Material and method. This retrospective study was conducted at a single institution, with data collected over 2 years (01.01.2017-01.01.2019). The variables examined were age, tumor location with regard to the gastric wall, the results of the intraoperative endoscopy, intraoperative and postoperative complications, the surgical technique, and histopathological reports. Results. We identified 12 relevant cases, of which 8 were females and 4 males. The average tumor diameter was 2.3 cm. The majority of the lesions were located on the anterior gastric wall (8 cases), on the small curvature (2 cases), and in the pyloric region (2 cases). Intraoperative endoscopy was performed successfully in 10 cases in order to identify the lesions and guide the resection. The average operative time was 120 minutes and the average hospital stay was 5 days. The gastric wall with the lesion was resected using an Ultrasonic device, a 2-cm oncological safety margin was preserved. Conclusion. Complete surgical resection independent from the tumor size represents the current optimal treatment. From a surgical point of view, these tumors must be considered malignant and the surgeon must respect principles of oncological surgery. Maintaining tumor integrity at dissection is critical for the patient’s long-term prognosis. Laparoscopic resection independent of the tumor size is feasible.

En bloc greenlight laser enucleation of prostate (GreenLEP): about the first hundred cases.

To report the functional outcomes, perioperative morbidity and surgical learning curve key points using "en bloc" greenlight enucleation of prostate (EB-GreenLEP) for patients with refractory lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Between December, 2015 and May, 2018, all consecutive patients with refractory LUTS due to BPH in our institution were included and underwent EB-GreenLEP by a single surgeon. Perioperative data, complications and functional outcomes at 1-, 6- and 12-month follow-ups were collected and retrospectively analyzed. One hundred patients were included whose median age was 69years. The median prostate volume (PV) was 84mL and median enucleated PV was 45.5mL. Mean irrigation, catheterization and hospitalization times were 1.3, 1.4 and 1.6days, respectively. Average follow-up was 9.3months. A single high-grade Clavien-Dindo complication occurred. No urinary retention was reported. Two conversions to conventional resection of the prostate were noted. Three patients had postoperative urinary incontinence at 6months, only one at 1year (1%). At 1, 6 and 12months, there was a significant improvement in IPSS score, QoL and Qmax. Enucleation and energy efficiency ratios were shorter after the 30th procedure. We demonstrated a linear correlation between enucleation time and PV (r = 0.53, p < 0.0001). Our study shows that the mid-term functional results of EB-GreenLEP are comparable to other laser sources for the endoscopic enucleation of the prostate but with a shorter learning curve. We showed that, with (a) low rates of complications and a short hospital stay, EB-GreenLEP can manage medium-size glands (60-90mL).

Preoperative conditioning and surgical strategies for treatment of complex abdominal wall hernias

The successful treatment of complex abdominal wall hernias requires individualized and if necessary interdisciplinary treatment concepts. Due to the high potential for abdominal and cardiopulmonary complications, specialized centers with ahigh level of expertise and experience should undertake the care of patients. Prehabilitation and optimization of hernia-specific risk factors and comorbidities play an essential role in the treatment algorithm. Preoperative conditioning prior to surgery can be crucial for success. Bariatric surgery for weight loss and administration of botulinum toxin Ain the lateral abdominal wall for stretching the musculature to provide myofascial advancement and enlargement of the torso diameter are parts of such strategies. The preoperative progressive pneumoperitoneum has its justification in massive evisceration, facilitates repositioning of the viscera and helps the patient to slowly adapt to the postoperatively changed abdominal pressure conditions. From a surgical technical point of view, the following principle should apply: "mesh augmentation comes before defect bridging". This means preference should be given to amorphological functional restoration of the myofascicular abdominal wall compared to procedures that merely bridge abdominal wall defects based on meshing. The retromuscular preperitoneal mesh strengthening in the sense of a sublay technique is the gold standard. This can be extended to anterior or posterior component separation techniques in order to achieve a reduction of tension to the midline and/or to achieve enlargement of the space for mesh placement.

Time-Dependent Biopathological Alternations In Carotid Atherosclerotic Plaques From Symptomatic Patients

Background and Aims: Stroke is one of the most common causes of death in industrials societies. Nevertheless, little is known about the optimal surgical time point after the occurrence of a neurological index event (IE) in symptomatic patients. The aim of the current work was to determine disease-relevant pathological factors, following the event. Particular attention was put on macrophage subtypes and fate decision in smooth muscle cells (SMCs) within the atherosclerotic plaques.

Robotic Surgery for Malignant Liver Disease: a Systematic Review of Oncological and Surgical Outcomes.

Robot-assisted laparoscopic surgery is yet another modification of minimally invasive liver surgery. It is described as feasible and safe from the surgical point of view; however, oncological outcomes need to be adequately analysed to justify the use of this technique when resecting malignant liver tumours. We reviewed existing English medical literature on robot-assisted laparoscopic liver surgery. We analysed surgical outcomes and oncological outcomes. We analysed operative parameters including operative time, type of hepatectomy, blood loss, conversion rate, morbidity and mortality rates and length of stay. We also analysed oncological outcomes including completeness of resection (R status), recurrence, survival and follow-up data. A total of 582 patients undergoing robot-assisted laparoscopic liver surgery were analysed from 17 eligible publications. Only 5 publications reported survival data. The overall morbidity was 19% with 0.2% reported mortality. R0 resection was achieved in 96% of patients. Robotic liver surgery is feasible and safe with acceptable morbidity and oncological outcomes including resection margins. However, well-designed trials are required to provide evidence in terms of survival and disease-free intervals when performed for malignancy.

JEJUNAL ADENOCARCINOMA: A CASE REPORT

Tumors of the small intestine are extremely rare, and clinical signs and symptoms are nonspecific, resulting in prolongation of the diagnosis process and subsequently worsening the outcome of the treatment. In addition to non-specific symptomatology, additional difficulty in diagnosing is the very inaccessibility of the jejunum through endoscopic techniques. The following is a review of the case of a female patient with jejunum carcinoma. CASE REPORT. A 64-year-old patient with nonspecific symptoms of fatigue, weight loss and sore pain in the stomach initially hospitalized due to anemic syndrome. An endoscopic evaluation was performed, and the fining was chronic gastritis. The patient was prescribed with iron supplementation therapy and was sent home. Within a month, the fore mentioned symptoms started to intensify, and the patient was hospitalized at the General Hospital in Skopje, where extensive investigations were conducted. Upper digestive endoscopy was made, and the finding again only showed chronic gastritis. Due to lack of findings, the doctors performed abdominal ultrasonography that indicated only a bolded intestinal segment with a thick wall of 9mm in the projection of the left flexure to the descending colon. The need for additional investigations grew and computed tomography with contrast of the abdomen and small pelvis was performed. The finding of the computed tomography was in favor of an irregular intestinal segment in the projections of the jejunal convolutions, with a thickened heterogenic wall and pathological post-contrast coloring. Due to the need for correlation with other trials, MRI was performed, and its finding was highly suspected of a tumor change in the jejunum, but an inflammatory disease was not excluded. Because of this finding, the patient was sent to the Department of Digestive Surgery at the same facility. From a surgical point of view, the patient was treated with an upper medial laparotomy, which made it possible for the tumor to be released from its surroundings. The surgery and after surgery course and the patient’s condition were all as expected. The patient was in a stable general condition after the surgery, and she was sent home. The pathophysiological finding resulted in jejunal adenocarcinoma (Latin adenocarcinoma intestinijejuni). After the pathophysiological finding was obtained, the patient was referred to an oncologist for eventual adjuvant therapy. DISCUSSION. Small intestine carcinoma is a specific clinical and surgical entity, which is often diagnosed in an already overdue phase. This is due in part to the non-cohesive symptomatology, but largely due to the still insufficiently sophisticated detection methods. Because of this enigmatic nature of these carcinomas, it may be necessary to think of a special team in the digestive surgery departments, which would solely work on this pathology, in order to speed up diagnosis and improve the outcome of the treatment for the patient.

Occupational health risk of pressurized intra-peritoneal aerosol chemotherapy (PIPAC) via endoscopical microcatheter system.

e14231 Background: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is becoming an increasingly widespread approach for delivering intra-peritoneal chemotherapy (IPC) by means of a chemoaerosol. In current studies, a flexible and easy-to-handle endoscopic microcatheter (MC) approach has been introduced to replace the conventional micropump used in PIPAC. While this new method has many advantages such as wide availability, cost effectiveness and improved drug distribution, its possible occupational health risks remain unknown. Methods: PIPAC was performed on three post mortem swine using the MC device. According to standard protocol in patients, solutions of doxorubicin and oxaliplatin were aerosolized in a standardized procedure room with laminar flow. Multiple probes of all surgical material including instruments and sutures, surrounding area surfaces and the operating personals’ items such as gloves and gowns were collected. Moreover, the air filter of the operating room was examined for doxorubicin and oxaliplatin concentrations. Results: The majority of probes showed no measurable doxorubicin or oxaliplatin concentrations. No exposure was detected on the operating personals’ gowns as well as the surrounding area surfaces. While a few of the surgical materials as well as the personals’ gloves and the main part of the application system showed low drug exposure, no drug exposure was measurable in the room filter. Conclusions: Our ex-vivo data suggest that PIPAC delivered via MC is safe and does not exhibit any major occupational hazards if the safety protocol is followed. MC offers an improved, easy-to-handle and cost-effective alternative to the micropump used in conventional PIPAC. Furthermore, the MC offers the great advantage of flexibility which allows access even in anatomically difficult situations and reduces the surgical point of entry to only one abdominal trocar placement.

Safety Control Method of Robot-Assisted Cataract Surgery with Virtual Fixture and Virtual Force Feedback

Surgery is an effective means of treating cataracts and restoring vision. However, cataract surgery rate (CSR) in developing countries and regions is relatively low due to the lack of experienced high-level surgeons. In this paper, to reduce the reliance of surgery on physician experience and thereby increase CSR, a master-slave robotic system and safety control strategies with a virtual fixture and virtual force feedback are proposed to assist cataract surgery. First, the surgery is divided into four different stages with different robot control modes. Secondly, the virtual constraint area with virtual spring model in the operating stage is established, so that the doctor can distinguish the operation area where the end of the surgical instrument is located by feedback force. Thirdly, safety control algorithm guarantees that the surgical instrument strictly moves around the surgical incision point, which is regarded as a remote centre of motion, so that the cornea outside the incision point is not injured. Finally, the experimental results show that the proposed safety control strategy allows the robotic system to perform the procedure safely.

Real-Time Single-Walled Carbon Nanotube-Based Fluorescence Imaging Improves Survival after Debulking Surgery in an Ovarian Cancer Model.

Improved cytoreductive surgery for advanced stage ovarian cancer (OC) represents a critical challenge in the treatment of the disease. Optimal debulking reaching no evidence of macroscopic disease is the primary surgical end point with a demonstrated survival advantage. Targeted molecule-based fluorescence imaging offers complete tumor resection down to the microscopic scale. We used a custom-built reflectance/fluorescence imaging system with an orthotopic OC mouse model to both quantify tumor detectability and evaluate the effect of fluorescence image-guided surgery on post-operative survival. The contrast agent is an intraperitoneal injectable nanomolecular probe, composed of single-walled carbon nanotubes, coupled to an M13 bacteriophage carrying a modified peptide binding to the SPARC protein, an extracellular protein overexpressed in OC. The imaging system is capable of detecting a second near-infrared window fluorescence (1000-1700 nm) and can display real-time video imagery to guide intraoperative tumor debulking. We observed high microscopic tumor detection with a pixel-limited resolution of 200 μm. Moreover, in a survival-surgery orthotopic OC mouse model, we demonstrated an increased survival benefit for animals treated with fluorescence image-guided surgical resection compared to standard surgery.

Accuracy of 3-dimensional–printed Endodontic Surgical Guide: A Human Cadaver Study

IntroductionCone-beam computed tomographic (CBCT)-based 3-dimensional–printed surgical guides, such as those used in implant placement and orofacial surgery, allow for accurate planning and performance of surgical procedures. The objective of this study was to evaluate the accuracy of CBCT-designed surgical guides for use during endodontic surgery. MethodsA split-mouth design was conducted using 48 roots in a cadaver model. In the experimental group, using information from the preoperative CBCT scans and digital impressions, surgical guides were designed using Blue Sky Bio (Grayslake, IL) planning software and printed using a Form 2 3-dimensional printer (Formlabs, Somerville, MA). The guides were designed to allow for surgical access at 3 mm from the apex of each root with depth control to the lingual or palatal surface of the root. In the control group, surgical access was completed “freehand” by visually approximating measurements from the CBCT scan only. The planned and postoperative CBCT images were superimposed, and the deviation of the surgical access point from the planned target was measured using Invivo software (Anatomage, San Jose, CA). A 2-tailed t test and the Fisher exact test were conducted to compare the deviation in the experimental CBCT-guided group versus the control CBCT-approximated freehand group. ResultsThe mean deviation for the guided group (1.743 mm) was significantly less than that of the approximated freehand group (2.638 mm, P < .001). Only in 11 of the 24 samples of the control group was surgical access considered clinically successful (within the apical area of the root), whereas all 24 of the experimental samples were considered clinically successful. ConclusionsUsing a CBCT-designed printed surgical guide is a more accurate method for access to the apical portion of the root during surgical endodontics compared with a “freehand” CBCT-approximated method.

Anatomic and clinical study of endoscopic assisted surgery via supraclavicular approach in thoracic outlet syndrome

Objective To explore the anatomical basis and simulated operation of a new minimally invasive treatment for thoracic outlet syndrome (TOS) through supraclavicular approach. Methods Local dissection in both sides was performed at lateral and anterior neck region in 5 cadavers. The endoscopic approach and operative plane were determined according to their anatomical characteristics, and the distance from the approach point to the transverse cervical artery was measured. Endoscopic surgery was simulated on a fresh cadaver to observe the tissue level and perform the release of brachial plexus. Results The distance between sternum head of sternocleidomastoid muscle and mastoid process was (13.78±0.94) cm. The distance between the cross border of the posterior border of sternocleidomastoid muscle and the upper border of the 5th root of brachial plexus and sternal head was measured (7.79±0.60) cm, which account for (56.58±2.78)% of the total length of sternocleidomastoid muscle. The anatomical study showed the optimum surgical entrance point: 60% of the total length of sternal head to mastoid process, 60° to the healthy side of the head, and 1 cm of longitudinal incision. The incision was performed on fresh human specimens and the transverse cervical artery was the landmark anatomical structure under the endoscope. Conclusion Supraclavicular approach endoscopic minimally invasive treatment for TOS is feasible, which can clearly expose brachial plexus nerve to perform brachial plexus neurolysis operation. It has clinical application value. Key words: Thoracic outlet syndrome; Dissection; Endoscopes; Surgical approach

Letter to the Editor Regarding “Hypnosis-Aided Awake Surgery for the Management of Intrinsic Brain Tumors versus Standard Awake-Asleep-Awake Protocol: A Preliminary, Promising Experience”

Hypnosis could extend the time of Intraoperative Neuropsychological Testing and Brain Mapping in Awake Surgery. A clinical validation for the Hypnosis aided AS (HAs) is still ongoing and further evidences are required. The objective of the present study is to compare two homogeneous cohorts of patients undergoing AS, the first with the aid of the hypnosis and the second according to a standard AS (SAs) protocols. The clinical, radiological and surgical data of two comparable procedures cohorts were retrospectively examined for the present study. All surgeries in Group A were performed with a HAs protocol. Procedures belonging to Group B were performed with a SAs protocol. Endpoints: to compare 1. Incidence of complications in the immediate postoperative period, 2. Clinical and neurological status in the immediate postoperative period and 30 days after surgery, 3. Duration of surgical interventions, 4. Extent of Resection (EOR). The final cohort is composed of 15 procedures; 6 belonging to Group A and 9 to Group B. The different methods outline statistically comparable results from the clinical (Neurological outcomes) both in the postoperative period and one month after surgery and from the surgical point of view (comparable EOR). The incidence of complications is comparable either. The duration of the procedures was significantly longer in HAs group. Hypnosis is a promising approach to increasing the duration of intraoperative “testability” of patients at the price of a longer operative time. A specific professional is needed to induce hypnosis in the difficult intraoperative setting.

Tomographic evaluation of the prevalence of the intraosseous branch of the posterior superior alveolar artery

Background: Despite being well documented and relatively safe, sinus lifting procedures can result complications. Aims: This study aimed to evaluate the presence of the intraosseous branch of the posterior superior alveolar artery (ibPSAA) at the surgical access point for maxillary sinus floor elevation procedure. Materials and Methods: A total of 583 tomography slices of 89 patients were analyzed for the presence or absence of this branch. The frequency of the presence of the artery, its diameter, its distance to the maxillary sinus floor, and its distance to the alveolar ridge according to the anatomical region related to the mentioned teeth were also measured. Results: The ibPSAA was visualized using the tomography in 50 patients (56.2%); a total of 583 tomography slices were evaluated and the vessel was identified in 219 slices. The artery had a diameter smaller than 1 mm in 67.9% of the cases and >1 mm in 32.1% of the cases. Conclusion: The present study provides information regarding the anatomy, presence, and most frequent location and size of the ibPSAA and revealed a risk of considerable hemorrhage in 32.1% of the cases, as the ibPSAA had a diameter >1 mm.