Teflon Pledgets Research Articles

Optimized microvascular decompression surgery for improving the results of hemifacial spasm: an analysis of reoperations.

Microvascular decompression (MVD) surgery is an effective curative treatment for hemifacial spasm (HFS). This study aims to establish techniques that may lead to favorable outcomes by analyzing reoperations in patients with persistent or recurrent HFS.Patients who exhibited persistent or recurrent HFS symptoms after prior MVD surgery were identified as candidates for reoperation. Information regarding the reoperations was collected by tracing the entire surgical procedures and peri-operative management. Clinical manifestations and follow-up data were obtained from the hospital records and subsequent visits.Twenty-six patients underwent repeat MVD surgery. Among them, multi-culprit neurovascular compression (NVC) was identified as the primary cause of failure to response to the previous operation in 73.08% of cases. Pure tissue adhesion accounted for 38.46% of cases, while shredded Teflon pledget (STP) shifting was observed in 7.69% of cases. Postoperative outcomes were assessed through revisits and categorized into four groups: excellent (76.92%), good (15.38%), fair (7.69%), and poor (0%). The longest follow-up period exceeded 65 moths.The trans-lateral suboccipital infra-floccular approach provides a better visual field. Examination of entire length of the facial nerve is essential. STP with gelatin sponge implantation is a suitable material for facilitating nerve and vascular positioning and reducing adhesion.

Etiology and Management of Recurrent and Persistent Hemifacial Spasm-A Single-Center Experience.

Despite a 90% success rate, microvascular decompression occasionally fails to resolve hemifacial spasm (HFS), necessitating revision surgery. We investigated recurrent cases to identify underlying causes. We evaluated patients at our institution who underwent revision microvascular decompression because of recurrent or persistent HFS, assessing recurrence causes, decompression techniques, complications, and outcomes. Data considered included demographics, preoperative symptoms, disease duration, offending vessel, and magnetic resonance findings. Surgical notes and intraoperative videos were reviewed, and telephone interviews were conducted for recent outcomes. Out of our ongoing series of 493 patients, 43 patients (8.7%) required revision surgery with a patient cohort of 33 females and 10 males. The average symptom duration was 10 years. The median time between primary and revision surgery was 14 months. Thirteen patients (30.2%) underwent initial surgery elsewhere. Adhesions of Teflon pledgets to the facial nerve were the primary cause of nonresolution in 23 patients (53.5%), while in 13 (30.2%), a missed vascular compression was identified. Sixteen patients (37.2%) had sufficient decompression by removing the conflicting pledgets. During 10 revisions (23.3%), additional Teflon pledgets were necessary. After a median follow-up of 67 months after revision surgery, 27 patients (62.8%) reported complete spasm resolution. Six patients (14.0%) had a good outcome with over 90% reduction of their spasms, 3 patients (7.0%) stated a fair outcome (50% improvement), while 7 patients (16.3%) had no improvement. According to our results, adhesions of Teflon to the facial nerve may cause HFS recurrence. Therefore, whenever possible, Teflon should be placed without nerve contact between the brainstem and the offending vessel. Using a sling or bridge technique seems to be beneficial because it leaves the facial nerve completely free. Persistent symptoms often result from missed offending vessels in the pontomedullary sulcus indicating the benefit of endoscopic inspection of this area with an endoscope.

Bridge technique for hemifacial spasm with vertebral artery involvement: 2-Dimensional operative video

Microvascular decompression for hemifacial spasm (HFS) associated with the vertebral artery (VA) is more challenging than that for small arteries. Atherosclerotic VA and tortuous VA are associated with a low success rate and high incidences of complications. Artery relocation employing a Teflon sling is helpful for small arteries. However, a different decompression technique should be considered in VA-related HFS due to the stiffness of the offending artery. With our simple decompression technique providing a secure transposition that can be performed even in the narrow cistern, a rigid Teflon bar is inserted to hold up all offending vessels between the pontine surface and the cerebellar flocculus (the bridge technique). This simple technique easily creates a free space over the root entry zone (REZ), reduces surgical manipulation compared to conventional artery relocation with a Teflon sling, and provides more secure nerve decompression than inserting Teflon pledgets on the REZ. The critical factors for successfully performing the bridge technique are using a rigid Teflon bar that can hold the rebound force of the VA and a length appropriate to generate a free space over the REZ between the pons and the cerebellar flocculus. In this video, we demonstrate our bridge technique for VA-related HFS and discuss the advantages and disadvantages of this novel approach.

ASCENDING AORTIC ANEURYSMS: SURGERY, RMODELLING & AI

ASCENDING AORTIC ANEURYSMS: SURGERY, RMODELLING & AI

How Strong Can We Pull? Critical Thresholds for Traction Forces on the Aortic Annulus: Measurements on Fresh Porcine Hearts.

Background and Objectives: Friable or infected tissue remains a challenge in surgical aortic valve replacement. We recently described the “Caput medusae” method, in which circumferential tourniquets temporarily secure the prosthesis and are then gently knotted. Tourniquets have been shown to develop significantly less force than knots. The current study investigates the critical threshold forces for tissue damage to the aortic annulus. Materials and Methods: In 14 fresh porcine hearts, the aortic valve leaflets were removed and several pledgeted sutures were placed along the annulus at defined locations. The hearts were mounted in a self-constructed device. Incremental traction force was applied to every suture and continuously recorded. The movement of each Teflon pledget was filmed with a high-speed camera. Forces at the moment of pledget “cut-in” as well as complete “tear-out” were determined from the recordings. Results: The average threshold force was determined 9.31 ± 6.04 N for cut-in and 20.41 ± 10.02 N for tear-out. Detailed analysis showed that the right coronary region had lower threshold forces than the other regions (4.77 ± 3.28 N (range, 1.67–12.75 N) vs. 10.67 ± 6.04 N (1.62–26.00 N) for cut-in and 10.67 ± 4.04 N (5.40–18.64 N) vs. 23.33 ± 9.42 N (9.22–51.23 N) for tear-out). The findings are discussed in conjunction with the knot and tourniquet forces from our previous study. Conclusions: Even in healthy tissue, moderate forces can reach a critical level at which a Teflon pledget will cut into the annulus, while a complete tear-out is unlikely. The right coronary portion is more susceptible to damage than the remaining regions. When compared to previous data, forces during manual knotting may exceed the critical cut-in level, while rubber tourniquets may provide a higher safety margin against tissue rupture.

New tools in minimal invasive aortic valve surgery: case report

Video 1 This is a standard case of aortic valve regurgitation of a 65 years old female, with known disease since 2008 and symptomatic in functional class II. At the echo valved looked bicuspid. The operations scheduled was aortic valve replacement with a tissue valve (actually was a CE num 19) through a J sternotomy. An innovative device composed by two staples, called RAM® and the other SEW-EASY®, was intended to use for suturing the prosthesis. Also, the use of another well-known device, aimed to tied suture, called COR-KNOT® was established. After central cannulation and selective delivery of cardioplegia, aortic cusps are resected. With the RAM® device the two ends of the tread with the Teflon pledget are passed equidistant in the aortic annulus, after previous loading of the stitch in to the device. Then, with the called SEW-EASY® device, stitches are also symmetrically passed thought the sewing ring of the prosthesis. After the prosthesis is parachuted, the COR-KNOT® device was used to finally tied the stitches. The intraoperative echo showed well positioned prosthesis, without paravalvular leak.

Zanimljiv slučaj koronarno-kameralne fistule sa anginom pektoris

Introduction: Coronary-cameral fistula (CCF) is an anomalous connection between a coronary artery and a cardiac chamber. Most CCFs are discovered incidentally during angiographic evaluation of coronary vascular disorders. We report a case of CCF with angina pectoris. Case report: A 67-year-old woman presented with chest pain and dyspnea upon exertion. Coronary angiography showed atherosclerotic lesions in the two major coronary arteries, but also communication between three arteries and the cavity of the right ventricle (RV) through many small, diffuse fistulas. Angiography also showed a fistula between the proximal left anterior descending artery (LAD) (first septal branch) and the right ventricle, as well as between the proximal right coronary artery (RCA) (acute marginal branch) and the right ventricle. The patient qualified to undergo coronary artery bypass graft surgery (CABG) and surgical closing of the fistulas, which is why we performed, on a beating heart, double vessel revascularization by autovein graft between the ascending aorta and the RCA and between the ascending aorta and the LAD, as well as closing of the fistulas with hemoclips and polypropylene suture, with a teflon pledget. Conclusion: Hemodynamically insignificant fistulas, which are clinically silent and not associated with other abnormal findings, most commonly do not require further treatment. Large, hemodynamically significant fistulas should be closed by ligation. However, smaller fistulas tend to get larger with age and it is recommended that early elective closure is performed in patients experiencing symptoms or in asymptomatic patients with a continuous murmur or a systolic murmur with an early diastolic component.

Hybrid Approach with Angiography and Limited Open Exposure to Treat Type Ia Endoleaks after Endovascular Aortic Aneurysm Repair

Type Ia endoleaks after endovascular aortic repair (EVAR) almost always mandate secondary percutaneous reinterventions. Several patients, however, will require conversion to open surgical repair with complete graft explant, which is associated with significant morbidity and mortality. We herein present 3 cases of hybrid surgical repair for type Ia endoleaks, using a limited open exposure for proximal stent graft edge revision to achieve graft preservation and effective aneurysm sac exclusion. Angiography was used to confirm type Ia endoleak in 3 patients (2 males) who had previous EVAR between October 2017 and October 2019. Time to the endoleak after the index EVAR was immediate in 1 patient during repair of a ruptured aneurysm, 2 months in 1 patient and 2 years in 1 patient. The aorta was exposed through a limited transabdominal (n = 1) or retroperitoneal (n = 2) approach and circumferential aortic control was achieved below the renal arteries. A row of interrupted horizontal mattress sutures of 3-0 polypropylene reinforced with Teflon pledgets was placed along the aortic neck circumference. Multi-planar angiography was then repeated to verify the absence of sac filling and successful type Ia endoleak exclusion. Follow-up abdominal duplex was obtained for all 3 patients after discharge to monitor the stent graft and confirm endoleak resolution. Furthermore, there were no instances of acute renal failure. In the period of review, 77 patients underwent EVAR. In the 3 patients described, we were able to achieve complete aneurysm sac exclusion and stent graft preservation in all cases. Follow-up imaging was available on 2 patients at 4-6 weeks after surgery demonstrating sustained exclusion of the endoleak. Two patients died during follow-up: one from a myocardial infarction 7 weeks after surgery and one from metastatic lung cancer at 8 months after surgery. Follow up duplex imaging at one year on the single survivor demonstrated sac shrinkage and absence of endoleak. Type Ia endoleaks represent a significant source of morbidity and mortality after EVAR and typically require repair to avoid aneurysm rupture. Our use of limited proximal revision without explant provides an alternative approach to resolve the endoleaks while reducing the magnitude of physiological stress when compared to an open explant. It represents a feasible option for high-risk patients.

Hemifacial Spasm: Endoscopic Assistance in Facial Nerve Decompression With Lateral Spread Response Corroboration: 2-Dimensional Operative Video

This video depicts the case of a 48-yr-old female with 3 yr of progressive left hemifacial spasm (HFS) refractory to medication. Magnetic resonance imaging showed a large anterior inferior cerebellar artery (AICA) and also a labyrinthine artery loop around the facial nerve (FN) root exit zone. A large bony eminence was also noted in the superior and lateral aspects of the porous acousticus (PA). She preferred surgery if "cure" was possible in lieu of Botox injections. A left retro sigmoid craniotomy was performed with brainstem auditory evoked responses (BAERs) and FN monitoring along with lateral spread response (LSR) assessment. The large bony prominence was drilled in its lateral aspect. Despite this, visualization was still limited and therefore we utilized a 30-degree-angled endoscope to observe the vessels caudal and cranial to the FN. This view prompted us to then drill further at the PA to decompress the FN as well as mobilize the labyrinthine artery away from the nerve. The LSR showed a dramatic improvement when FN decompression was accomplished, and then a further improvement with arterial mobilization and Teflon pledget placement. The BAERS remained at baseline throughout. FN function and hearing were intact on postoperative clinical assessment. Her symptomatic improvement was recorded at 12 mo after surgery. This video illustrates a more complex case of microvascular decompression with skull base concepts and techniques. The patient provided consent for the procedure and use of her images and operative video for publication.

Case report of recurrent hemifacial spasm attributed to over-impaction with Teflon sponge

Background: Hemifacial spasm (HS) is a muscular disorder frequently exacerbated by arterial compression amenable to surgical intervention through microvascular decompression (MVD). Recurrence is a known cause and warrants investigation.Case Description: A 65-year-old woman presented with the left HS of 7 years duration. Her symptoms were initially well controlled with botulinum toxin injections. However, these injections eventually lost their effectiveness, necessitating MVD. At surgery, the anterior inferior cerebellar artery was indenting the facial nerve at its root entry zone. This was carefully dissected away, and several Teflon (polytetrafluoroethylene) felt pledgets were used for decompression. Postoperatively, the patient reported great improvement of her symptoms for 3 months. Gradually her spasms returned, intermittently at first, until finally they became persistent 6 months postoperatively. An MRI was obtained showing elevation and posterior displacement of the VII-VIII complex by the pledgets. After failing to improve, the patient opted for reoperation 10 months after initial MVD. At surgery, the Teflon pledgets were displacing the VII-III nerves posteriorly and superiorly. The Teflon pledgets were dissected free, and the nerve dis-impacted. On her postoperative visit 1 year later, she is spasm free, subjectively, and objectively.Conclusion: This case illustrates the value of re-imaging recurrent HS, and re-exploration with a favorable rkesult.

Obstructive pneumonia owing to migration of a Teflon pledget at 8\u2009years after surgery for a pulmonary carcinoid tumor: a case report

BackgroundIt is uncommon for a bronchial stump-related complication to develop during the remote postoperative period in a case of obstructive pneumonia owing to migration of the suture material. Here, we describe a case of bronchial obstructive pneumonia that developed owing to migration of the suture material in the airway 8 years after pulmonary resection.Case presentationA 34-year-old woman underwent left lower lobectomy for a pulmonary carcinoid tumor (pT1bN0M0-stage IA) in 2010. She experienced obstructive pneumonia, and chest computed tomography revealed a mass protruding from the bronchial stump to the bronchial lumen in 2018. After treatment for pneumonia, flexible bronchoscopy showed the presence of a fibrous suture material (Teflon pledget) completely obstructing the left second carina. A week later, the Teflon pledget obstructing the bronchial lumen was removed using a flexible bronchoscope with the patient under general anesthesia. The procedure was completed without removing the small amount of granulation tissue because the bronchial lumen opened after removing the Teflon pledget. She has remained asymptomatic for 1 year after removal.ConclusionsIn this case, the complication of obstructive pneumonia developed owing to migration of the non-absorbable suture materials used to suture the bronchial stump. Bronchoscopic management of this rare complication comprised endobronchial removal with the patient under general anesthesia. Given our experience with this case, we believe that such conservative management should allow for excellent results in most instances and avoid the need for reoperation.

Microvascular Decompression for Geniculate Neuralgia through a Retrosigmoid Approach.

Objectives To describe a retrosigmoid approach for the microvascular sectioning of the nervus intermedius and decompression of the 5th and 9th cranial nerves, with emphasis on microsurgical anatomy and technique. Design A retrosigmoid craniectomy is performed in the lateral decubitus position. The dura is opened and cerebrospinal fluid (CSF) is released from the cisterna magna and cerebellopontine cistern. Dynamic retraction without rigid retractors is performed. Subarachnoid dissection of the cerebellopontine angle exposes the 7th to 8th nerve complex. A neuromonitoring probe is used with careful inspection of the microsurgical anatomy to identify the facial nerve and the nervus intermedius as they enter the internal auditory meatus. The nervus intermedius is severed. A large vein coursing superiorly across cranial 9th nerve was coagulated and cut. A Teflon pledget is inserted between a small vessel and the 5th nerve. Photographs of the region are borrowed from Dr. Rhoton's laboratory to illustrate the microsurgical anatomy. Participants The senior author performed the surgery. The video was edited by Drs. V.N. and J.B. Outcome Measures Outcome was assessed by postoperative neurological function. Results The nervus intermedius was successfully cut and the 5th and 9th nerves were decompressed. The patient's pain resolved after surgery and at later follow-up. Conclusions Understanding the microsurgical anatomy of the cerebellopontine angle is necessary to identify the cranial nerves involved in facial pain syndromes. Subarachnoid dissection and meticulous microsurgical techniques are key elements for a successful microvascular decompression. The link to the video can be found at: https://youtu.be/pV5Wip7WusE .

Endoscope-Assisted Microvascular Decompression for the Management of Hemifacial Spasm Caused by Vertebrobasilar Dolichoectasia

Vertebrobasilar dolichoectasia (VBD) is a rare cause of hemifacial spasm. The ectatic vessel hinders microscopic visualization of the root exit zone. The aim of this study was to evaluate the benefit of endoscopic visualization during microvascular decompression (MVD) in managing this type of neurovascular compression. Retrospective evaluation of patients with VBD treated by endoscope-assisted MVD for hemifacial spasm between 2007 and 2016 was performed. A prospectively maintained database of all patients treated by MVD for hemifacial spasm was screened for vascular compression. Magnetic resonance imaging was evaluated to detect patients who had VBD according to defined criteria. The value of endoscopic inspection to detect offending vessels was analyzed, and clinical outcome was evaluated. VBD was detected in 11 of 290 patients (incidence 3.8%). In these patients, 12 MVD procedures were performed. The endoscope was useful in identifying the offending vessels and adjacent perforators without any brain retraction in all patients. At last clinical follow-up, all patients had almost complete to complete resolution of clinical symptoms. The interposing technique alone was effective with excellent results in 8 patients. Three patients required an additional transposition-fixation technique to achieve sufficient decompression. VBD is a rare cause of hemifacial spasm. Because of the large diameter of the offending vessel, MVD is technically more demanding. Endoscopic inspection with a 45° endoscope enables accurate visualization of the root exit zone, offending vessels, and perforating arteries. Furthermore, accurate placement of the Teflon pledgets can be confirmed leading to a favorable outcome.

Microsurgical Decompression of Trigeminal Neuralgia Caused by Simultaneous Double Arterial (SCA and AICA) and Petrosal Vein Complex Compression.

Trigeminal neuralgia is a chronic pain disorder affecting the face. In approximately 80% of cases, it is most commonly caused, when the root entry zone (REZ) of the trigeminal nerve is compressed by the superior cerebellar artery (SCA). The etiology of the remaining 20% of cases is distributed among venous, arteriovenous malformations, posterior fossa tumors, multiple sclerosis plaque compressions, and other pathologies. Combinations of those compressive factors are very rare. 1 2 3 4 Herein, we present a video clip of microvascular decompression (MVD) in a 73-year-old female, who has failed conservative treatment with 6 medications over 10 years. She was affected by a unique triple compression of the right REZ by the SCA, anterior inferior cerebellar artery (AICA), and petrosal vein complex ( Fig. 1A ). Right-sided microsurgical decompression of the REZ of the trigeminal nerve through standard retrosigmoid craniotomy was performed by the senior author (K.I.A.). The SCA and AICA were separated from the nerve using Teflon pledgets. The petrosal vein complex was coagulated and divided, freeing up the right trigeminal nerve ( Fig. 1B ). The patient was discharged home on the third postoperative day with complete resolution of trigeminal neuralgia. The link to the Video can be found at: https://youtu.be/PYVvImGW0yE .

P.022 Hemifacial Spasm due to dolichoectatic vertebrobasilar artery compression

Background: Hemifacial Spasm (HFS) is rarely caused by a dolichoectatic vertebrobasilar artery (eVB) compression of the Facial Nerve. This can pose a surgical challenge when performing microvascular decompression as vessel mobilization is often difficult due to atherosclerosis, tethering from brainstem perforators, and large size. These patients are often not considered for surgery. Methods: A retrospective chart review of patients who were surgically treated by the senior author between 2003 and 2017 with an admitting diagnosis of HFS was performed. Patients with preoperative neuroimaging demonstrating eVB compression of their facial nerve/root were included. Results: During the 15-year review, 315 patients underwent microvascular decompression for HFS and 21 (6.7%) had dolichoectactic vertebrobasilar compressions. At final followup (>3 months) 19 patients (90.4%) experienced reduction in symptoms with 15 (71.4%) having complete resolution. One patient required re-operation and benefitted from subsequent symptom relief. The majority of culprit compression was found proximally on the pontine surface. Mobilization of the culprit vessel was achieved successfully in the majority of cases with Teflon pledgets. There were no perioperative strokes or death. Complications are presented Conclusions: Microvascular Decompression for Hemifacial Spasm caused by dolichoectatic vertebrobasilar artery compression can be performed with a high rate of safety and success in the setting of a high case volume centre.

Carotid-Falciform Optic Neuropathy: Microsurgical Treatment.

Several recent reports have implicated vascular ectasia and vessel contact in dysfunction of the visual apparatus. A subset of patients with prechiasmatic visual deterioration have an ectatic internal carotid artery (ICA) that displaces and flattens the optic nerve (ON) rostrally as the ON exits the skull base. We describe a proposed pathophysiologic mechanism and a straightforward surgical technique for dealing with this problem. Via an ipsilateral pterional craniotomy, the bony roof of the optic canal is removed. The falciform ligament is opened in parallel to the ON. Adhesions between the ICA and ON are then dissected, and a Teflon pledget is placed between the ICA and ON to complete the decompression. Patients both in the literature and in this series experienced an improvement in their vision postoperatively. We propose that 3 mechanisms contribute to this caroticofalciform optic neuropathy: 1)mass effect from ICA ectasia, 2) ON irritation from vessel pulsatility, and 3) indirect compression by the falciform ligament from above. This disease process can be treated safely using standard microsurgical techniques with excellent outcomes.

The influence of side branch stenosis on fractional flow reserve assessment of the main branch in a swine model.

The aim of this study was to explore the effect of one stenosis in a daughter artery on the fractional flow reserve (FFR) of another stenosis parallels in side branch. The impact of one stenosis on the FFR of another parallel stenosis has not been evaluated. The proximal segments of the left anterior descending (LAD) and left circumflex (LCX) arteries were exposed and encircled with a Teflon pledget complex in seven swine (55-70 kg). Five degrees of stenosis (to approximate angiographic diameter stenoses of 0%, 25%, 50%, 75%, and 100%) were made by tightening the pledgets. FFR was evaluated simultaneously in the LAD and the LCX with two pressure wires in each coronary artery. A mixed-effects linear model was used to evaluate the association between the FFR values. A total of 115 paired FFR values were obtained. The FFR of the LAD and LCX were not significantly associated with each other (F = 0.237 and P = 0.627 for the LCX FFR to predict the LAD FFR; F = 0.541 and P = 0.463 for the LAD FFR to predict the LCX FFR). The individual FFR values of each parallel stenosis in the LAD and the LCX were not significantly influenced by each other. This relationship was independent of the mean aortic pressure and heart rate. © 2016 Wiley Periodicals, Inc.

Conservative Surgical Management for Pulmonary Hydatid Cyst: Analysis and Outcome of 148 Cases.

Background. Hydatid cyst (HC) disease is endemic in many developing countries, like Yemen, Egypt, and Saudi Arabia, especially in the rural regions. The disease has a variable clinical courses and even might be asymptomatic for many years. Objectives. In giant and large pulmonary hydatid cysts, pulmonary resection is the usual method of surgical treatment. In this study, we aimed to evaluate the lung conservative surgery in treatment of cases with giant and large hydatid lung cysts, as an effective method of management. Patients and Methods. Between January 2009 and August 2014, a total of 148 patients with pulmonary hydatid cysts were operated and their data was reviewed retrospectively and analyzed. Out of these cases, 52 (35.14%) cysts with more than 10 cm in diameter and 36 (24.32%) cysts with 5–9 cm were regarded as giant and large hydatid lung cysts, respectively. The small cysts less than 5 cm were presented in 8 (5.4%) cases only; other cases had ruptured cysts. Preservation of the lung tissues during surgery by cystotomy and Capitonnage was our conservative surgical methods of choice. Results. Eight patients developed bronchopleural fistula (BPF); of them, 4 BPFs have healed with chest tube and physiotherapy, but in the other 4 patients reoperation was done for the closure of persistent BPF. No mortality was observed in the present study. Conclusion. We conclude that conservative surgical procedure can achieve complete removal of the pulmonary hydatid cyst. Enucleation of the intact huge cysts is safe. Careful and secured closure of the bronchial communication should be done by purse string or figure-of-8 sutures, with or without Teflon pledgets. These simple procedures are safe, reliable, and successful.

PTH-150 Giant hiatus hernias in the laparoscopic era

<h3>Introduction</h3> Laparoscopic repair of giant hiatal hernias (LRGHH) remains a major technical challenge in the successful management of this complex surgical pathology. The aim is to present herein our experience and highlight technical tips in ensuring a safe and efficient approach that improves outcome. <h3>Method</h3> A retrospective review of patients undergoing elective LRGHH for symptomatic disease was undertaken between January 2011 and September 2014. Size of hiatal defect, herniated contents, surgical variations were recorded and correlated with clinical outcomes. <h3>Results</h3> Sixteen LRGHH surgeries were performed by three consultant surgeons [A=8, B=4 and C=4, respectively]. There were six males and 10 females with a median age of 65 years (range 33–74). There were eleven Type 3 and five Type 4 hernias with hiatal defect ranging from 2.8 to 7 cm. Complete sac excision, meticulous crural dissection and repair and Nissen undoplication were performed in all cases. Collis gastroplasty for shortened oesophagus was fashioned in 4 cases, mesh applied in 1 case and Teflon pledgets in further 3 cases. Eight (50%) patients remained asymptomatic at 6 weeks, five (31%) reported minimal reflux that had settled at 4-month follow up. Complications occurred in 3 patients (18.7%) and included: immediate hernia recurrence with gastric necrosis requiring laparoscopic sleeve gastrectomy, recurrent vomiting that underwent laparoscopic adhesiolysis 18 months post initial procedure and post-operative dysphagia requiring endoscopic dilatation. All 3 patients remained symptom free at 24 months. <h3>Conclusion</h3> This report represents the largest reported series in the UK in the modern laparoscopic era. Extensive oesophageal mobilisation to ensure adequate intra-abdominal length and strong crural repair with minimal tension are key to a successful repair. Minimally invasive surgery for such complex major pathology allows perioperative morbidity to remain low with good early outcomes. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases Luketich JD, Raja S, Fernando HC, Campbell W, Christie NA, Buenaventura PO, Weigel TL, Keenan RJ, Schauer PR. Ann Surg. 2000;232(4):608–18 Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients Pierre AF, Luketich JD, Fernando HC, Christie NA, Buenaventura PO, Litle VR, Schauer PR. Ann Thorac Surg. 2002;<b>74</b>(6):1909–15; discussion 1915–6

A Novel Suture Technique for Distal Aorta-Graft Anastomosis in Aortic Aneurysm Repair Surgery: Diagonal Basting Stitch

We describe a novel suture technique of distal anastomosis between the graft and the aorta in ascending aortic aneurysm repair surgery. In this technique, the aortic graft is positioned inside the distal aortic lumen with an overlapping segment and circumferential or back wall part only diagonal basting stitches are performed without use of Teflon pledgets, strips, or bioadhesives. This new technique establishes a secure anastomosis line, shortens anastomosis time, and avoids the use of foreign materials.