Three-layer Closure Research Articles

Surgical management of type III and IV laryngotracheoesophageal clefts: The three-layered approach

The objective of this paper is to present our surgical experience with a cohort of four infants with laryngotracheoesophageal cleft (LTEC) in order to highlight our early failures and complications and to propose a comprehensive, three-layered approach in treating stages III and IV LTEC. An IRB approved, retrospective chart review was carried out of a cohort of four cases occurring within a 2-year period of time. All patients had other significant anomalies, and the mortality rate was high: 75%. After our initial failures and difficulties with recurrent fistulas, tracheomalacia and tracheotomy dependence, we were able to achieve a successful outcome of a functional separation of the airway and the digestive tract without a tracheotomy in our last two patients. Unfortunately, both these patients died from factors not directly associated with the LTEC so long-term follow up was not possible. We now have one survivor, our second case, who is tracheotomy dependent. Laryngotracheoesophageal clefts are rare congenital anomalies with high morbidity and mortality despite various forms of surgical repair. Fistulas, tracheostomy dependence, tracheomalacia, and chronic lung disease secondary to aspiration are frequent problems following LTEC repairs. We advocate an anterior approach to the cleft repair, a three-layered closure of the cleft to include an interpositional muscular flap, and a physiologic repair of the posterior larynx with a standard cartilage graft technique used in laryngotracheal reconstruction.

A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes

OBJECTIVE To review the outcomes of consecutive patients referred with urethral diverticula to a tertiary centre; to investigate the diagnostic, imaging and surgical factors relevant to success. PATIENTS AND METHODS A retrospective case note review of 30 consecutive patients treated between January 1999-2007 was performed and data retrieved on demographics, presenting symptoms, preoperative imaging, surgical technique, outcomes and need for further intervention. RESULTS All patients were tertiary referrals, four after failed local repairs. The mean (range) interval between initial presentation and repair was 48 (1-264) months. Only seven patients (23%) had all three symptoms of the classical triad of dysuria, dyspareunia and dribble, whilst 23% did not have any of these symptoms. Transvaginal ultrasonography showed the diverticulum in six of nine patients, voiding cysto-urethrography (VCUG) in 13 of 18 patients (72%) and magnetic resonance imaging (MRI) in all 11 patients assessed. MRI accurately imaged diverticular configuration, whilst VCUG assessed detrusor and sphincteric function. Twenty-nine (97%) patients were cured of their diverticulum; all 19 patients with simple diverticula were cured at first attempt, whilst 17 procedures were performed on the 11 patients with complex diverticula. Twenty of 24 (83%) repairs were successful using three-layered closure, 9 of 11 using Martius interposition, and one using bulbospongiosus muscle interposition. There were three primary repair failures; two circumferential diverticula repaired with Martius interposition and one partial horseshoe diverticulum repaired without interposition had partial recurrences. Both were subsequently repaired successfully. One patient with chronic urethral pain from multiple, infected recurrences was eventually diverted. A pubovaginal sling procedure was required in only one (3.3%) patient with persistent pre-existing stress urinary incontinence (SUI). CONCLUSIONS The presentation of urethral diverticula is diverse and diagnosis frequently delayed. The most useful preoperative imaging is MRI and VCUG to assess diverticular anatomy and detrusor/urethral function, respectively. In simple cases, transvaginal excision with three-layer closure is curative, whilst more extensive, persistent or SUI-associated diverticula require Martius fat interposition. Sling procedures can be deferred until the results of primary excision are assessed.

Management of soft-tissue trauma to the face

The management of acute soft-tissue trauma can be very challenging for the facial plastic surgeon. The goals of management of facial trauma are the preservation of form and function. These goals are particularly important in facial soft-tissue trauma, where injuries can cause not only esthetic deformities but also can affect neural function, normal mastication, visual fields, and salivary outflow. This article outlines the evaluation and treatment of acute soft-tissue facial trauma. The key components include allowing for the stabilization of the patient, complete examination of the injury and face, thorough wound irrigation and debridement of necrotic tissue, preservation of all viable tissue, tension-free closure, and realignment of important facial esthetic structures. Special consideration must be given to injuries of functional structures such as the facial nerve, ductal systems or organs, and ensuring appropriated management of these structures.

Repair of Rectal Injury During Robotic-Assisted Laparoscopic Prostatectomy

Rectal injury is a potential devastating complication in radical prostatectomy. We reviewed the incidence and management of rectal injuries with robotic-assisted laparoscopic radical prostatectomy performed by a single surgeon. Of the first 251 robotic-assisted laparoscopic radical prostatectomies performed, 2 (0.8%) were complicated by rectal injury. All patients underwent bowel preparation and received preoperative intravenous antibiotics. Both rectal injuries were detected intraoperatively and treated robotically. The rectotomy was closed in two layers of absorbable sutures and imbricated with a nonabsorbable suture. The rectum was then tacked to the levator fibers on one side with nonabsorbable suture to pull the injury away from the vesicourethral anastomosis. An omental flap was developed and tacked posterior to the urethra to cover the repair. A closed suction drain was placed. After surgery, the patients received broad-spectrum intravenous antibiotics and resumed oral intake on postoperative day 1. At 2 weeks, the Foley catheter was removed after voiding cystourethrography confirmed no extravasation. Rectal injury during robotic-assisted laparoscopic radical prostatectomy can be identified and managed intraoperatively without requiring open conversion. A three-layer closure tacked away from the vesicourethral anastomosis and reinforced by an omental flap resulted in an uneventful recovery.

Porencephalic Cyst

To discuss the first reported case of spontaneous cerebrospinal fluid (CSF) otorrhea caused by a massive CSF-containing porencephalic cyst. A case report and review of the literature (MEDLINE 1962-2005). A tertiary neurotologic referral center. A 65-year-old woman with congenital hemiplegia presented with left-sided spontaneous CSF otorrhea of 4-month duration. An audiogram revealed a mixed hearing loss. High-resolution computed tomography revealed a thinning of the tegmen and epitympanum without an obvious defect. Magnetic resonance imaging revealed a massive porencephalic cyst essentially replacing the entire left cerebral hemisphere. A transmastoid approach with three-layered closure was used to successfully repair the sieve-like defects that were discovered in her tegmen. The patient remains free of drainage, and the conductive hearing loss has resolved. Spontaneous CSF otorrhea caused by a porencephalic cyst is an uncommon cause of conductive hearing loss that has never been reported before. Only a few cases of traumatic CSF otorrhea/rhinorrhea associated with a porencephalic cyst have been reported. A high level of suspicion, a beta2-transferrin assay, and appropriate radiographic imaging are required for diagnosis in adults without a history of trauma, meningitis, chronic ear disease, or previous ear surgery.

Three-layer closure of a tracheoesophageal puncture site: A technical note

A tracheoesophageal voice prosthesis is highly effective in promoting good speech after total laryngectomy. However, long-term use of this device occasionally results in the development of fistulas that must be closed, usually at the request of the patient, because of leakage of saliva and food around the prosthesis. This report describes a technique for simple 3-layer closure of the tracheoesophageal puncture site; other procedures are discussed in light of the current literature.

Repair of Iatrogenic Temporal Lobe Encephalocele after Canal Wall Down Mastoidectomy in the Presence of Active Cholesteatoma

Although mastoid and middle ear obliteration provides the ultimate repair of an encephalocele, retained squamous epithelium may result in the occult recurrence of cholesteatoma. For most patients, a preferable technique is to perform a canal-wall-up mastoidectomy with middle fossa craniotomy. However, temporal lobe encephaloceles are occasionally found in patients with canal-wall-down cavities along with active cholesteatoma. We sought to describe our management strategy for this dilemma. Retrospective review. Tertiary referral center. We reviewed all patients with encephaloceles treated by the primary surgeon. Patients without active cholesteatoma and a canal-wall-down cavity were excluded. Surgical management of the encephalocele and cholesteatoma. Successful repair and a noninfected ear. Three patients met the inclusion criteria. All had previous canal-wall-down surgery for cholesteatoma by outside surgeons and presented with chronic otorrhea, large tegmen defects, and brain herniation into the mastoid cavity. All had incomplete removal of their posterior canal wall. Our management strategy involved completing the canal-wall-down mastoidectomy and repairing the temporal floor defect using a three-layer closure via a middle fossa craniotomy. This included suture repair of the dural defect with or without a graft, a temporalis muscle rotation flap, and a split-calvarial bone graft. All patients recovered from their surgery without evidence of further cerebrospinal fluid leak, encephalocele, or cholesteatoma with a minimum follow-up time of 6 months. A temporal lobe encephalocele can be safely repaired while maintaining a mastoid bowl. This may be the safest treatment option for patients with active cholesteatoma.

Minilaparotomy myomectomy: A minimally invasive alternative for the large fibroid uterus

To assess the efficacy of performing myomectomies through 3- to 6-cm incisions for the removal of myomas up to 14 cm in diameter. A retrospective analysis of 139 myomectomies performed at our center from January 1995 through December 2003 (Canadian Task Force classification II-3). A suburban medical center, part of a large prepaid health maintenance organization. One hundred thirty-nine women. Myomectomies were performed through 3- to 6-cm suprapubic cruciate incisions using atraumatic elastic retractors with or without laparoscopic assist. Myomas were morcellated with a scalpel before being enucleated. The uterus was repaired in a classic three-layered closure in all cases. All procedures were performed in the ambulatory surgery unit of our hospital, which is part of the main operating room. The median age of the patients in this series was 30.0 years (range 23-56 years). The median weight of the myomas removed was 275.0 g (range of 30-975 g). One hundred thirty-seven (98.5%) of 139 patients were discharged in 23 hours or less, with 24 patients leaving within 4 hours and 61 within 8 hours. The median length of stay was 6.0 hours, with two patients remaining hospitalized for 48 hours. The median operating time was 110 minutes (range 44-260 min). Estimated blood loss ranged from 50 to 2000 mL, with a median of 300 mL. Three hysterectomies were performed: one as an emergency for hemorrhage and two for recurrent myomas. Three patients developed wound seromas, and one developed a wound infection. Minilaparotomy myomectomy is a safe, effective minimally invasive alternative to laparoscopic myomectomy. Early discharge and return to normal activities is comparable to laparoscopy and is far more cost effective. It affords the ability to palpate the uterus and close the myometrial defect easily with a standard three-layered closure making it particularly suitable for gynecologists with limited laparoscopic suturing skills.

Surgical repair of a cleft soft palate in an alpaca

A 26-day-old entire male alpaca was referred for surgical treatment of a cleft soft palate. Mandibular symphysiotomy and three-layer closure of the palatal defect resulted in primary intention healing. Despite complications related to anaesthesia the alpaca made a full recovery.

Closure of a Pharyngocutaneous Fistula Using a Sternomastoid Muscle Flap

Presented here is a case of a pharyngocutaneous fistula which was closed primarily using a sternomastoid muscle flap, without skin coverage, thus obviating the need for a three-layered closure. Providing an intermediate cover was sufficient for the closure because the mucosal lining on the inside and the cutaneous covering on the outside grew using the muscle for support.

Spontaneous Cerebrospinal Fluid Leakage and Middle Ear Encephalocele in Seven Patients

Isolated cases of spontaneous cerebrospinal fluid (CSF) leakage with and without middle ear encephalocele have been reported. These leaks are usually accompanied by episodes of recurrent meningitis, hearing loss, or chronic headache. In this article, we report seven new cases of spontaneous CSF leakage. Six of these patients had conductive hearing loss and serous otitis media, and three had recurrent meningitis. Prior to a definitive diagnosis, six patients had received myringotomy tubes, which produced profuse clear otorrhea. Three patients had positive beta-2 transferrin assays. Computed tomography and magnetic resonance imaging confirmed a defect in the temporal bone tegmen. A combined transmastoid and middle fossa surgical approach with a three-layer closure was used to repair the tegmen defect. All patients had a lumbar drain placed prior to surgery. In addition to describing the seven new cases, we review the history of CSF leakage and discuss diagnostic methods, surgical findings, and our recommendations for management.

Three-layer closure of an oroantral-cutaneous defect

Reconstruction of oroantral defects, which are usually caused by tumor resection, is challenging. These defects become an even more difficult problem when they comprise multiple layers including oral mucosa, subcutaneous tissue, muscle and skin. This paper describes such a case in which a three-layer closure using a palatal flap, a buccal fat pad flap and a local skin flap was successfully performed.

Three-layer closure of an oroantral-cutaneous defect

Three-layer closure of an oroantral-cutaneous defect

Two-Flap palatoplasty: Bardach's technique

The two-flap palatoplasty technique, which I described for the first time in 1967, allows for complete closure of the palatal cleft, with two-layer closure in the area of the hard palate and three-layer closure of the soft palate. Using this technique, many palatal clefts can be close without leaving bare bone exposed lateral to the mucoperiosteal flaps in the area of the hard palate. Precise dissection of the muscles of the soft palate from the posterior edge of the bony palate and from the nasal periosteum allows for increased mobility as well as lengthening of the soft palate. Several key steps of this technique are presented in this paper. The results of our clinical studies revealed that normal speech production is achieved in approximately 75% to 80% of patients. Oronasal fistulas were found on the average of 5.2% in patients with all types of palatal clefts.

Atypical Cleft of the Palate: A Report

Our early experience with a rare atypical cleft of the soft palate in a 15-month-old female infant is presented. The cleft extended obliquely across the soft palate from the retromolar region on the left to the base of an intact uvula. Surgical management included a three-layer closure and lengthening of the left side of the soft palate. Close follow-up and reporting of the patient's progress are planned.

Atypical Cleft of the Palate: A Report

Our early experience with a rare atypical cleft of the soft palate in a 15-month-old female infant is presented. The cleft extended obliquely across the soft palate from the retromolar region on the left to the base of an intact uvula. Surgical management included a three-layer closure and lengthening of the left side of the soft palate. Close follow-up and reporting of the patient's progress are planned.

A Comparison of Three Techniques for Closure of Pelvic Flexure Enterotomies in Normal Equine Colon

Six enterotomies 3 cm long, spaced at 3 cm intervals, were made in the antimesenteric border of the pelvic flexure of the ascending colon in five adult horses. Ten incisions each were sutured with a Utrecht pattern (single layer), a full-thickness simple continuous oversewn with a Cushing pattern (two layer), and a mucosal simple continuous with a seromuscular simple continuous oversewn with a Cushing pattern (three layer). In all horses, chromic gut and polyglactin 910 were each used once for each pattern. On day 6, the pelvic flexure was excised and the colonic vessels were injected with a radio-opaque mass. Sections of each enterotomy were studied by light microscopy and high detail radiography. The single-layer closure led to serosa-to-mucosa healing and a thin bowel wall, and the three-layer closure resulted in distortion of the bowel wall by hematoma formation and submucosal contamination with ingesta. The two-layer closure resulted in good alignment and improved healing. There was less inflammatory reaction with polyglactin 910 than with chromic gut.

Surgery of the Aging Face

The following represent some of the highlights presented concerning surgery of the aging face at the Fifth International Symposium of Facial Plastic Surgery in Toronto, Canada, on June 28, 1989. Norman J. Pastorek, MD, New Rochelle, NY, presented a paper entitled, Refinements of the Rafaty Brow Lift. The author defined improvements of the original Rafaty direct browlift technique, with emphasis on incision placement, elevation of the orbicularis muscle, and meticulous three-layer closure technique. Clinical indications and possible complications were also discussed. Douglas D. Dedo, MD, West Palm Beach, Fla, presented a paper entitled vs Sub-SMAS Facelift. Dr Dedo reviewed 117 facelift procedures over a 5-year period. Included in this series were two patients who had received a sub-SMAS elevation and advancement procedure on one side and a SMAS plication procedure on the other. Dr Dedo was unable to clinically distinguish between the two sides 5 years postoperatively. Based on these observations, Dr Dedo suggests that plication may be just as effective in the long term as SMAS elevation and advancement.

Soft-tissue repair of myelomeningocele defects using bilateral latissimus dorsi and trapezius musculocutaneous flaps.

An urgent closure of myelomeningocele defects was carried out in 82 newborns using latissimus and/or trapezius musculocutaneous advancement flaps. A three-layer closure of skin, muscle, and fascia was achieved in a single stage without a flank skin graft. All of the wounds healed within a two-week period and no late breakdown of the wound occurred during the eight-year period of study. The urgent closure maximized the neurological salvage and facilitated early cerebrospinal fluid shunting by preventing both infection and neural desiccation. This report represents the largest number of sequentially treated myelomeningocele defects without a major wound healing problem or death. The advancement musculocutaneous flap closure is safe, simple, and effective and is recommended as the preferred method for closure of the myelomeningocele defect.

Techniques in Eyelid Wound Closure

While one of the most basic techniques in eyelid surgery is the repair of an eyelid defect that involves the margin, many eyelid defects are still poorly repaired; and much confusion still exists in this area. Based upon sound anatomic and surgical principles, we suggest several modifications of classically described techniques: (1) The greyline suture is replaced by a tarsal suture through the meibomian gland orifices to provide a stronger closure and better alignment. (2) All tension of closure is supported by the deep tarsal sutures rather than by the margin sutures to avoid notch formation or unsightly scars. (3) A two-layered closure where orbicularis and tarsus is closed in a single layer is technically easier and gives results comparable to the classically taught three-layered closure. Conjunctival sutures in the tarsal portion of the eyelid are unnecessary and frequently cause corneal irritation. (4) When lid resection is performed, a pentagonal excision rather than a "V" or wedge resection should be used to minimize tension on the margin when closed. We present in an illustrated step-by-step fashion our preferred technique which gives consistently good results.