Surgical Tips Research Articles

Cranioplasty With Hydroxyapatite Implants: A Multidisciplinary Approach of Neurosurgeon and Plastic Surgeons to Improve Surgical Technique and Clinical Outcome.

Cranioplasty using Hydroxyapatite prosthesis is a conceptually simple procedure, but it may harbor several challenges for the surgeons. Several papers in the literature deal with cranioplasty using porous hydroxyapatite. The results are not homogeneous both because of the variability of the patients treated but also because Hydroxyapatite requires a more careful surgical technique to achieve maximum performance. The aim of the present study is to offer an insight of a single institution, multidisciplinary experience with custom-made Hydroxyapatite cranioplasty with surgical tips and tricks based on personal opinion and literature evidence. We will provide an overview of all the fundamental steps we believe to be useful to optimize surgical outcomes, including preoperative planning of cranioplasty; as cranioplasty flap/soft tissue coverage planning, infectious prophylaxis, patient positioning, incisional patterns, tissue dissection, primary bone demolition, and preparation of the craniectomy margins before implant positioning. The authors will also discuss methods for dural suspension, implant fixation and anchorage, margins polishing, drainage, suturing, and dressing. Cranioplasty using hydroxyapatite prosthesis is a valuable alternative for skull reconstruction with heterologous implants, and in our opinion a multidisciplinary approach integrating plastic surgeons and neurosurgeons' specific skills can facilitate surgical planning, reducing complications and allowing to achieve better functional and aesthetic results.

Abbe Flap for Upper Lip Reconstruction.

Lips are complex structures that are part of the facial esthetics. Their integrity may be affected by congenital diseases, trauma, burns, and cancers, among other pathologies. The reconstruction of the upper lip subunit can be a challenge for the surgeon. The purpose of this paper is to review the Abbe flap technique with the help of tips from the primary surgeon (surgical tips) and present a series of cases as experience in upper lip reconstruction. A retrospective study at Chilean centers Fundación Gantz and Clínica Alemana de Santiago from 2003 to 2023. The surgical technique was described, and different variables were assessed. The Strasser scale was used as an objective method for assessing the results. Sixteen surgery patients, 50% female and 50% male. Fourteen patients (87.5%) with cleft lip and palate. In total, 85.71% of the total number of patients with follow-up had a good score of 1 to 4 on the Strasser scale. There were no mediocre results comparable to results described in other series. There were no complications relating to the technique. The Abbe flap technique continues to be an excellent option in upper lip reconstruction, especially in patients with a condition of the middle third of the lip. Knowledge of the anatomy, the surgical technique, the function of the lip, and facial esthetics leads to acceptable results for the patient and their environment with this technique.

Feasibility of a less invasive supercharged end-to-side anterior interosseous nerve to ulnar motor nerve transfer.

The object of this study was to perform an anatomical dissection of Thiel-embalmed specimens in a step-by-step procedure, to establish a 'safe zone' in which to perform a less invasive supercharged end-to-side (SETS) anterior interosseous nerve to ulnar motor nerve transfer without tension and to demonstrate its feasibility. The sample size was calculated with a 5 mm error to reach a 95% confidence interval. Dissection was performed in 15 specimens and the 'safe zone' was established between 40 and 90 mm proximal to the pisiform. Several surgical tips are recommended to help complete the procedure. A reproducible 'safe zone' was found for performing a SETS anterior interosseous to ulnar motor nerve transfer with 95% certainty, reducing soft tissue damage and enhancing the original surgical technique.

When the Going Gets Tough: A Review of Total Hip Arthroplasty in Patients with Ipsilateral Above- and Below-Knee Amputation.

Life expectancy and overall function of amputated patients have improved significantly over the last few decades; for this reason, amputees are more exposed to primary or secondary degenerative disease of the hip, requiring total hip arthroplasty (THA) surgery. However, during training, not all the surgeons acquire adequate skills to manage these patients, and only a few studies and case reports describe technical pearls and outcomes of THA in patients with ipsilateral lower limb amputation, either above or below the knee. The objective of this narrative review is to present current evidence and surgical tips for performing THA in ipsilateral amputated patients, with a focus on the differences between patients with above- (AKA) and below-knee amputation (BKA). We reviewed manuscripts in major scientific databases, cross-referencing to retrieve adjunctive manuscripts, and summarized all relevant cases. We found 17 manuscripts, spanning 70 years of literature, collecting a total of 39 patients who underwent THA on an ipsilateral amputated limb: 13 AKA, 23 BKA, and 3 through-knee-amputation (TKA). The cohort primarily consists of patients with post-traumatic hip arthritis, often associated with sequelae such as fractures to other bones, soft tissue compromise and heterotopic calcifications. Managing with amputated patients requires careful planning, which includes the study of the residual bone, muscle anatomy, and the level of femoral amputation, as these factors present significant surgical challenges, especially in patients without a knee joint. In dealing with the post-traumatic and multi-comorbidity patients, rehabilitation goals should be considered prior to surgery and should drive the surgical strategy. We found that BKA patients typically have high functional demands, necessitating precise positioning of the components and an aggressive post-operative physiotherapy regimen to avoid unsatisfactory outcomes. AKA patients, on the other hand, often present with altered anatomy, and typically require more surgical instruments and expertise to achieve intraoperative dislocation of the hip joint.

Surgical Tips for Robotic Assisted Laparoscopic Abdominal Cerclage: A Minimally Invasive Approach.

Preterm birth is the leading cause of perinatal and neonatal morbidity and mortality in the developed world. An important cause of preterm birth is cervical insufficiency, leading to membrane prolapse, premature rupture of membranes, and mid-trimester pregnancy loss. A cerclage can be placed vaginally or abdominally to treat cervical insufficiency. In cases of failed prior transvaginal cerclage (TVC), transabdominal cerclage (TAC) is the alternative. The procedure can be completed via laparoscopy or open approach. The suture is placed at the internal os giving greater structural support.1 In this article, we review the definition of cervical incompetence, we present the indications for TAC, we discuss the outcomes of minimally invasive TAC compared to open approach, and we review surgical tips and tricks for robotic assisted (RA) TAC placement that can be used prior to pregnancy or in early gestation. The included images delineate the surgical technique for safe placement of robotic assisted laparoscopic abdominal cerclage in the management of cervical insufficiency.

510. INNOVATIVE ROBOTIC-ASSISTED ESOPHAGECTOMY WITH THREE-FIELD LYMPHADENECTOMY: A NOVEL APPROACH TO ESOPHAGEAL CANCER SURGERY

Abstract Background Esophageal squamous cell carcinoma, the predominant form of esophageal cancer in Thailand, often presents at advanced stages (III - IV), necessitating surgical intervention. Radical esophagectomy, including three-field lymphadenectomy, stands as one of the most invasive gastrointestinal surgeries. However, in the era of minimally invasive surgery (MIS), robotic systems have emerged as a formidable approach to achieve radical treatment goals while minimizing surgical invasiveness. This video showcases a novel surgical technique and its challenges. Methods A case of mid-thoracic esophageal squamous cell carcinoma, clinically staged III, treated via robotic-assisted esophagectomy and three-field lymphadenectomy using the Da Vinci Xi system. The operation encompassed three phases: Initially, the thoracic phase with patient in semi-prone position with three robotic and one assistant trocars for complete esophageal mobilization and mediastinal lymph node retrieval. The abdominal phase, followed by the cervical phase, utilized four robotic trocars and one assistant trocar in supine position with hyperextended neck, facilitating perigastric lymph node retrieval, gastric tube reconstruction via the posterior mediastinal route, and cervical esophago-gastric tube anastomosis using a circular stapler. Results The patient experienced an uneventful recovery. Postoperative esophagogastroduodenoscopy on day 1 revealed the integrity of the anastomosis and normal vocal cord function. Imaging conducted on day 7 confirmed that the anastomosis was patent without any leakage. Surgical outcomes included an operative time of 615 minutes, estimated blood loss of 150 ml, a 14-day hospital stay, and recovery without complications. This video highlights the intricacies of the procedure and the robotic system's ability to access anatomically challenging spaces, thereby minimizing surgical invasiveness and enhancing recovery. Conclusion The robotic system is capable of performing radical procedures in anatomically challenging areas, such as narrow spaces and areas requiring precise maneuverability among vital structures. It enables a comprehensive approach spanning from the upper to the lower thoracic regions and diversity of surgery in thoracic and abdominal cavity. Additionally, this presentation highlights unique surgical tips and techniques that enhance the safety and feasibility of robotic-assisted esophagectomy. By significantly reducing surgical errors and optimizing outcomes for both oncologic and minimally invasive surgeries, it thereby marks a significant leap forward in the field of esophageal surgery. https://drive.google.com/file/d/1vrmu2D8TGoetnplcREPWQocXJle4PrOX/view?usp=share_link

Tips and Tricks to Save You During Revision Total Knee Arthroplasty

The number of revision total knee arthroplasties (TKAs) performed annually continues to rise. This article is a summary of a symposium on revision TKAs presented at the 2023 American Association of Hip and Knee Surgeons annual meeting. It will provide an overview of the surgical tips and tricks for exposure and component removal, use of metaphyseal fixation and stems to manage bone loss and optimize fixation, constraint in TKA, as well as how to manage extensor mechanism disruptions with a synthetic mesh reconstruction. Level of evidenceV.

How I do it. Pancreatojejunostomy: surgical tips to mitigate the severity of postoperative pancreatic fistulas after open or minimally invasive pancreatoduodenectomy.

Pancreatoduodenectomy is the most appropriate technique for the treatment of periampullary tumors. In the past, this procedure was associated with high mortality and morbidity, but with improvements in patient selection, anesthesia, and surgical technique, mortality has decreased to less than 5%. However, morbidity remains increased due to various complications such as delayed gastric emptying, bleeding, abdominal collections, and abscesses, most of which are related to the pancreatojejunostomy leak. Clinically relevant postoperative pancreatic fistula is the most dangerous and is related to other complications including mortality. The incidence of postoperative pancreatic fistula ranges from 5-30%. Various techniques have been developed to reduce the severity of pancreatic fistulas, from the use of an isolated jejunal loop for pancreatojejunostomy to binding and invagination anastomoses. Even total pancreatectomy has been considered to avoid pancreatic fistula, but the late effects of this procedure are unacceptable, especially in relatively young patients. Recent studies on the main techniques of pancreatojejunostomy concluded that duct-to-mucosa anastomosis is advisable, but no technique eliminates the risk of pancreatic fistula. The purpose of this study is to highlight technical details and tips that may reduce the severity of pancreatic fistula after pancreatojejunostomy during open or minimally invasive pancreatoduodenectomy.

Single-Position Prone Lateral Lumbar Interbody Fusion Technique Guide: Surgical Tips and Tricks.

Lateral lumbar interbody fusion (LLIF) is a popular technique as it allows for the placement of a large interbody implant through a retroperitoneal, transpsoas working corridor. Historically, the interbody is placed with the patient in lateral decubitus and then repositioned to prone for the posterior instrumentation. While this has been an effective and successful technique, removing the interoperative flip would improve the efficiency of these cases. This has led to modified LLIF approaches including single-position prone LLIF (pLLIF). This modification has shown to be an efficient and powerful technique; however, learning to navigate the LLIF approach in the prone position has its own challenges. The purpose of this article is to provide a detailed description of our pLLIF technique while simultaneously introducing surgical tips to overcome the challenges of the approach and optimize the implantation of the interbody device.

Surgical tips and tricks for laparoscopic intragastric surgery for submucosal tumors relative to the esophagogastric junction.

Recent reports have described the practicality of laparoscopic intragastric surgery (l-IGS) as an alternative for resecting submucosal tumors (SMTs) near the esophagogastric junction (EGJ), where excision using an exogastric approach would be difficult. However, even using IGS to perform a full-thickness resection of SMTs that are in or extremely close to the EGJ is very difficult to do safely and avoid disrupting or causing stenosis of the EGJ, without advanced experience. This study retrospectively examined the usefulness of l-IGS for gastric SMTs located in or extremely close to the EGJ. Fourteen patients with gastric SMTs < 2cm of the EGJ and underwent l-IGS were eligible for this study. We examined the tumor location, operative time, intraoperative hemorrhage, degree of deformation, gastroesophageal reflux disease, perioperative complications, and recurrence. Furthermore, we compared patients with tumors in the EGJ with those with tumors near the EGJ and patients in whom three-port l-IGS was performed with those who underwent single-incision laparoscopic surgery. The average tumor size, operative time, intraoperative hemorrhage, and postoperative hospitalization of the 14 patients were 30.9 ± 21.3mm, 125.2 ± 31.1min, 30.7 ± 103.3mL, and 9.2 ± 3.1d, respectively. No differences in these parameters according to the type of l-IGS or tumor location were observed. All patients underwent l-IGS without complications and were free from EGJ deformation or esophagitis. We believe that l-IGS is useful for gastric SMTs located < 2cm of the EGJ as it can be safely performed for difficult tumor locations and does not cause deformation of the EGJ.

Glaucoma surgical procedure choice in vulnerable corneal endothelium

This talk will focus on the decision making in patients with vulnerable corneal endothelium requiring glaucoma surgical intervention. The effect of glaucoma surgical procedures on corneal endothelium will be briefly analysed and conditions with vulnerable corneal endothelium and co‐existent intraocular pressure (IOP) elevation, such as Fuchs corneal endothelial dystrophy with primary open angle glaucoma or post‐keratoplasty steroid response, will be adequately described. The aim of the talk is to indicate the most appropriate glaucoma surgical interventions depending on the status of corneal endothelium and the desired IOP lowering effect, covering a wide spectrum of surgical procedures including minimally invasive interventions, such as Preserflow implantation, as well as ab interno/ab externo viscocanaloplasty or conventional procedures such as trabeculectomy or big tube implantation. Finally, the talk will highlight useful surgical tips for the abovementioned surgical procedures, and it will provide suggestions for patient selection in order to optimize clinical outcomes.

Evaluation of Modified Shell Technique in 3D Ridge Reconstruction: A Clinical and Radiographic Study

Introduction: As a result of tooth loss, alveolar ridge resorption sacrifices bone volume including bone width. In order to replace the lost dentition with implants functionally and esthetically, bone augmentation procedures are carried out. Materials and Methods: Fifteen patients were selected to treat mandibular alveolar ridge resorption with an autogenous block graft harvested using piezoelectric surgical tips and split into two shells using a diamond disk then fixated on the decorticated defective ridge. Particulate xenograft bovine bone was then inserted between the fixated shell and ridge, the second shell was used to roof the bone particles. Results: The modified shell technique could be an alternative to other ridge augmentation techniques. This study shows promising clinical and radiographic results that carry the advantages of being: safe and precise cutting using Piezoelectric tips, the statistical data showed a significant difference in 3D bone volume where no unfavorable complication was detected. Conclusion: The modified shell technique showed a reliable technique in cases of 3D ridge reconstruction since it holds the advantages of autogenous bone properties and the rigidity of the bone shells that maintain the space necessary for augmentation. The use of PRF can accelerate wound healing and minimize the risk of flap dehiscence as well as it can speed up bone formation.

Surgical tips of duct-to-duct bile duct anastomosis in unusual situations in living donor liver transplantation

Surgical tips of duct-to-duct bile duct anastomosis in unusual situations in living donor liver transplantation

Lesson learned in endoscopic endonasal dens resection for C1-C2 spinal cord decompression.

Endoscopic endonasal approach (EEA) is the safest and most effective technique for odontoidectomy. Nevertheless, this kind of approach is yet not largely widespread. The aim of this study is to share with the scientific community some tips and tricks with our ten-year-old learned experience in endoscopic endonasal odontoidectomy (EEO), which remains a challenging surgical approach. Our case series consists of twenty-one (10 males, 11 females; age range of 34-84years) retrospectively analyzed patients with ventral spinal cord compression for non-reducible CVJ malformation, treated with EEA from July 2011 to March 2019. The results have recently been reported in a previous paper. The only intraoperative complication observed was intraoperative cerebrospinal fluid (CSF) leak (9.5%), without any sign of post-operative CSF leak. Considering our experience, EEO represents a valid and safe technique to decompress neural cervical structures. Despite its technical complexity, mainly due to the use of endoscope and the challenging surgical area, with this study we encourage the use of EEO displaying our experience-based surgical tips and tricks.

Single-incision laparoscopic surgery transabdominal preperitoneal approach for recurrent inguinal hernia: A case series of long-term follow-up

Introduction and importanceLaparoscopic surgery is recommended to treat recurrent inguinal hernia (IH). Single-incision laparoscopic surgery transabdominal pre-peritoneal (SILS-TAPP) has been an option for IH repair but few studies on the application of this method for recurrent IH was conducted. We aimed to report our experience of SILS-TAPP for recurrent IH and the long-term outcomes of this technique. Case presentationTen patients of recurrent IH, including three multiple recurrences, were successfully treated with SILS-TAPP. Previous surgeries were Bassini and Lichtenstein's procedures. No perioperative complications were observed; neither additional trocar nor conversion to open surgery was needed. Median operation time was 65 (range: 45–95) minutes. Post-operative pain lasted for two to three days. Neither long-term complications nor recurrence was seen until the median follow-up time of 37 (range: 16–53) months. Clinical discussionAlthough the surgical procedure of hernia repair of SILS-TAPP was the same as conventional TAPP, the manipulation of the instrument was technically challenging. This surgical method should be done by an SILS expert with application of several surgical tips to overcome difficulties adhering to single-port surgery. Also, meticulous and patient dissection of the inguinal site is suggested. ConclusionSILS-TAPP is safe and feasible to repair recurrent inguinal hernia. However, it should be done by experienced surgeons.

Technique Pearls for Successful Cervical Disc Arthroplasty From More Than 20 Years of Surgical Experience.

Surgical technique paper. To describe tips and pearls for cervical disc arthroplasty (CDA). CDA has proven to be an effective means of treatment for degenerative cervical disc disease and cervical radiculopathy in properly selected patients who have previously failed non-operative treatment. Surgical tips and pearls garnered from more than 20 years of experience with CDA surgery are described. This discussion focuses on pearls for successful procedures, including patient selection, patient positioning, surgical technique, and postoperative protocols. In correctly selected patients, CDA can be effective in treating cervical degenerative disc disease and radiculopathy. The techniques described here can increase the chance of success and decrease complications.

Total Knee Arthroplasty in a Patient with Ipsilateral Painless Hip Arthrodesis: Technical Surgical Tips and a Novel Method for Intraoperative Navigation-Assisted Planning.

Total knee arthroplasty (TKA) in the setting of a previous ipsilateral hip fusion/arthrodesis is an uncommon and challenging procedure. There is little information available in the literature on the challenges and techniques available to perform TKA in these patients. For a traditional TKA procedure, the patient is placed in the supine position and various knee-positioning devices are used to allow for adequate knee and hip flexion, which is required for surgical exposure and tibia preparation. Ipsilateral hip arthrodesis presents two major challenges: (1) Hip flexion is crucial for adequate knee flexion while the patient is supine during the TKA procedure, and (2) the use of advanced technology, specifically computer navigation and robotic-assisted surgery techniques, is limited due to the inability to acquire the hip center of rotation during surgery, due to the lack of hip motion. Therefore, equipment and positioning must be adjusted by the surgeon to facilitate TKA in these patients. This article reports the case of a 72-year-old male patient with a long-standing, painless right hip arthrodesis, presenting with end-stage osteoarthritis of the right knee, leg-length discrepancy, and an 11.6° difference between the mechanical and anatomical axes of the femur. We describe the unique surgical planning as well as the surgical positioning options that allow for adequate knee flexion and proper surgical exposure. Furthermore, we describe a novel method of computer-assisted navigation for intra-operative planning and execution utilizing a reflected tibia as a template for the distal femoral cut.

Cardiac surgery of aortic valve and ascending aorta (Bentall procedure) in a patient with Fabry disease without enzyme replacement therapy: an overview of aortic and aortic valve surgical tips

Introduction: Fabry disease (FD) is a rare disease in which cardiovascular events are one of its manifestations. Aortic and mitral valve involvement are among its manifestations, but due to the concern of suture failure without enzyme replacement therapy (ERT), the desire for its surgery has been very low, and its reported cases have been few. After the introduction of ERT, cardiovascular surgery for such patients has been gradually reported from different places, but due to the high cost of ERT, it is not practically available to patients in the third world and the backward countries. Reports of the experiences of patients with FD who underwent cardiac surgery without ERT can help improve cardiac surgery in these patients. Case Report: A 34-year-old man diagnosed with FD due to chronic renal failure and underwent dialysis 3 times a week for 1.5 years became a candidate for kidney transplant. In pre-transplant examinations, dilatation of aortic root and aortic valve insufficiency were diagnosed, and the patient’s kidney transplant surgery was postponed until after cardiac surgery. The patient underwent cardiac surgery, aortic valve replacement, and ascending aortic replacement, as well as re-implantation of both right and left coronary buttons on the ascending aorta (Bentall procedure). The post-surgery period passed without any special event. The patient’s dialysis continued; after 4 months, he underwent kidney transplant surgery, and the one-year follow-up period also was good. Conclusion: Although there is very little evidence of cardiovascular surgery in patients with FD without ERT, and surgeons have always been worried about suture failure and complications of cardiac surgery, due to the high cost of ERT, this treatment is not available to everyone. The introduced patient underwent cardiac surgery by Bentall procedure without receiving ERT and was discharged without any special complications. By reporting and collecting similar cases, guidance may be provided for patients with FD for whom ERT is not available.

Surgical Tips for Aesthetic Lower Lid Blepharoplasty: Prevention of Round Eye

Purpose: In the present study, we highlight surgical tips based on our experience in lower eyelid blepharoplasty. These have been shown to be crucial in the prevention of several complications, specifically lateral lower-lid displacement. Methods: A series of bilateral lower-lid blepharoplasties were performed on 280 patients at Humanitas-Research-Hospital (Milan, Italy) between January 2016 and January 2020. Patients with a history of lower-lid blepharoplasty and patients requiring canthopexy/canthoplasty were excluded. Needing to singularly evaluate and correct several lower-eyelid structures to obtain a harmonic result, we preoperatively assessed the amount of skin excess, the eyelid margin malposition relative to the globe, and the presence/absence of herniated fat-pads. Pre- and postoperative standard photographs were collected. Patients were evaluated by measuring scleral show, snap-back test, and distraction test. Blinded-fashioned photograph analysis was performed by independent plastic and oculoplastic surgeons who did not execute the procedures. A visual analogue scale was administered to all patients to assess satisfaction. Results: In total, 280 patients underwent successful lower blepharoplasty, with satisfactory results of scleral show, snap-back test, and distraction test. Of the 280 patients, four presented postoperative complications. At 10-month follow-up visit, we achieved a mean patient visual analogue scale satisfaction score of 8.4. Postoperative surgeon’s photographs mean score was 4.5. Conclusions: Without the use of muscle flaps, our technique averts tarsal ligament misposition, preserves orbicularis-muscle innervation, and limits thermal spread, assuring excellent stability of results and high patient and surgeon satisfaction. Cosmetic outcome in terms of symmetry, appearance, and lower lid line definition revealed high satisfaction with the result over time, with a remarkably low complication rate.

Lateral hinge fracture in medial opening wedge high tibial osteotomy: a narrative review.

Lateral hinge fractures (LHF) are one of the most common complications of medial opening wedge high tibial osteotomy (MOWHTO), and are the leading cause of construct instability displacement, non-union, and varus recurrence after this procedure. To date, Takeuchi's classification is the most popular classification to describe this complication, and it can help surgeons to make intra and postoperative decisions. Opening medial gap width is the most recognized factor related to LHF occurrence. Recognizing the implications of LHF in patients' clinical and radiographic results has led many authors to propose surgical tips and the use of osteosynthesis materials such as K-wires and screws for its prevention, which should be considered when identifying risk factors for LHF during preoperative planning. The evidence for determining the optimal management of LHF is scarce and mostly supported by experts' opinions and recommendations; therefore, studies are still needed to identify the most appropriate behavior when dealing with such a complication.