Traction Sutures Research Articles

Repurposing medical devices as "button" esophagostomy tubes for extended nutritional support.

BackgroundEsophagostomy tubes (E‐tubes) are widely utilized for extended nutritional support in dogs and cats. Problems associated with their use include the unwieldy excess (10‐20 cm) of external tubing, constant need for neck wraps and necessity for skin sutures, suture tract infection, and tube loss if sutures fail.ObjectivesTo evaluate 2 different, low profile (LP) “button” products intended for use in people as enteral (jejunostomy [J] and gastrojejunostomy [G‐J]) feeding tubes for suitability as LP E‐tubes in dogs and cats.AnimalsA young giant breed dog that required extended (>6 months) nutritional and fluid support during recovery from severe neurological illness with protracted adipsia, anorexia, and dysphagia.MethodsProspective evaluation of 2 commercially available LP feeding devices after placement of a standard E‐tube. An LP J‐tube and an LP G‐J tube were assessed in consecutive 4‐week trials, for tube retention, patient comfort, stoma health, and functionality.ResultsBoth products performed extremely and equally well as LP E‐tubes in this clinical patient, enhancing patient freedom and comfort by eliminating external tubing, skin sutures, and bandaging. The dual port G‐J tube allows medication delivery (eg, sucralfate) to the entire esophagus, but for safety alone (ie, to avoid aspiration), the single port J‐tube appears the best device for client‐owned patients.Conclusions and Clinical ImportanceThe LP enteral feeding tubes from the human medical field can be successfully used as LP E‐tubes in dogs and cats, offering superior patient comfort, with no obvious detriment to the patient and main drawback of higher cost.

Arthroscopic Transosseous Repair of a Medial Meniscal Posterior-Root Tear.

(1) Preoperative evaluation, including patient history, examination, and imaging (i.e., radiographs and magnetic resonance imaging). (2) Preparation and positioning. The patient is placed in the supine position, and anteromedial and anterolateral portals are created. (3) Placement of sutures. Two simple cinch sutures are placed into the posterior horn, within approximately 5 mm of each other. (4) Footprint decortication. Remove articular cartilage from the native root insertion site. (5) Drilling of the transosseous tibial tunnel. Introduce a tibial tunnel guide over the decorticated base, set guide to 45° to 50°, place a 2-cm vertical incision over an anteromedial tibial guide footprint, advance a 2.4-mm guide pin through the guide, and overream to 5 mm. (6) Passing of the sutures with use of a looped suture passer introduced retrograde through the tibial tunnel to retrieve sutures. (7) Anchor placement and fixation. Apply maximum suture traction, drill a second aperture 0.5 to 1.0 cm distal to the original aperture on the anteromedial aspect of the tibia, pass the suture ends through the anchor, and fix the anchor into the aperture. (8) Repair evaluation and closure. Note the position and stability of the meniscal root relative to the native footprint. Standard closure in layers is performed. If the patient experiences no relief from nonoperative treatment, an MMPRT can be treated operatively via partial meniscectomy or repaired via direct suture-anchor repair or indirect transosseous (transtibial) repair. Direct repair utilizes a suture anchor inserted at the root site5. Variations of the present technique include different suture configurations or numbers of tunnels. Although several suture configurations have been described, the simple cinch stitch (utilized in the present procedure) has been shown to be better at resisting displacement than the locking loop stitch6. Moreover, it has been suggested that simple stitches are less technically difficult and more able to resist displacement because they require less tissue penetration than other stitches7. Lastly, procedures that utilize a single versus a second transtibial tunnel have been shown to be equivalent in cadaveric studies8. The desired results of MMPRT repair include anatomic reduction, preservation of meniscal tissue and knee biomechanics, and preservation of hoop stress, which improve activity, function, and symptoms and mitigate degenerative changes and the risk of progression to total knee arthroplasty. At a minimum of 2 years after transosseous repair, the Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index, 12-Item Short Form, and Tegner activity scale were significantly improved8,9. Previous studies have shown significant improvement in the Hospital for Special Surgery and Lysholm scores without radiographic osteoarthritis progression at the same minimum follow-up10. Lastly, in the longest-term follow-up study to date, transosseous repair survivorship was reported to be 99% at 5 years and 92% at 8 years, with failure defined as conversion to total knee arthroplasty11. Pearls○ Decorticate the native meniscal root down to bleeding bone.○ Consider fenestration or percutaneous release of the medial collateral ligament in order to further open a tight medial compartment.○ A self-retrieving suture passer allows the use of standard arthroscopy portals.○ A multiuse variable-angle tibial tunnel drill guide allows point-to-point placement over the native meniscal root insertion.○ A guide with a tip may be easier and more accurate to control.○ Consider different guides when drilling the tibial tunnel, according to the anatomy of the patient.○ A low-profile guide may provide better clearance along the condyles.○ Utilize a cannula when shuttling sutures through the tibial tunnel in order to prevent a soft-tissue bridge.○ With anchor fixation, consider drilling over a guide pin and tapping when the bone is hard.○ Study preoperative imaging to evaluate the amount of arthritis present. Evaluate all compartments on magnetic resonance imaging for additional pathology.Pitfalls○ Obliquity of the tibial tunnel can cause the guide pin and reamer to enter too anteriorly.○ Patient failure to adhere to postoperative rehabilitation and restrictions can lead to unfavorable outcomes.○ The use of lower-strength sutures may increase the risk of fixation failure.

A Diaphragmic Traction Suture Increases Pleural Cavity Volume and Surgical Field Overview During Video-Assisted Thoracoscopic Surgery.

An elevated hemidiaphragm may impair surgical field overview during video assisted thoracoscopic surgery (VATS) and may consequently jeopardize a safe surgical procedure or prolong the duration of surgery. The aim of this study was to evaluate if tension applied to a diaphragmatic suture improves the surgical field overview. Following informed consent and at the surgeon's discretion during elective VATS procedures, a single stitch was placed at the posterior tendinous border of the diaphragm and retracted through the camera port. The surgical field overview was evaluated using a numeric rating scale (1-10) by the surgeon before and after applying tension during the procedure, and later by 9 VATS surgeons (> 10years' experience) using video recordings. During a 4-month period, 43 patients scheduled for elective VATS by two surgeons gave informed consent to participate. The hemidiaphragm was elevated to such an extent in 27 patients that the surgeon placed a diaphragmatic stitch suture. When tension was applied to the suture, surgical field overview improved significantly (p < 0.001). A diaphragmatic traction suture improves surgical field overview in selected patients with elevation of the hemidiaphragm. This simple procedure may facilitate VATS in patients with impaired surgical field overview and consequently improve safety during VATS. CLINICAL TRIAL NUMBER: http://ClinicalTrials.gov (No. NCT04837950).

Superior rectus recession for hypertropia in thyroid-associated ophthalmopathy

To assess the outcomes of superior rectus-weakening surgery in patients with thyroid-associated ophthalmopathy (TAO). The medical records of patients with TAO who were treated with surgical weakening of the superior rectus muscle at the Zhongshan Ophthalmic Center from 2008 to 2018 were reviewed retrospectively. Data collected included sex, age at surgery, duration of deviation, ocular alignment, ocular motility, surgical procedures, and outcomes. Surgical success was defined as the absence of diplopia and a vertical deviation of ≤5Δ in primary and reading positions. A total of 33 patients (mean age 45.7years; 17 males) were included. Of the 33 patients, 28 received unilateral superior rectus recession, with a success rate for primary surgery of 79%. The mean preoperative hypertropia of 35.1Δ ± 19.3Δ was significantly reduced to 3.9Δ ± 9.7Δ. Ocular infraduction restriction significantly improved from a preoperative average of -5.3±1.9 to -1.3±1.3 postoperatively. Five patients underwent superior rectus tenotomy, with only 2 cases having a successful final outcome. For 27 of 33 cases, only a single surgery was required; 6 cases required a second surgery. The overall final success rate was 76%. In our study cohort, superior rectus recession with or without traction suture for hypertropia in thyroid-associated ophthalmopathy resulted in a high rate of success.

Skin Traction Technique for Closure Large and Complex Skin Defects in Special Cases

Objective: During the period of COVID-19 pandemic, the reconstructive surgeons don't want to take risks of complex and long operations, and to struggle with long recovery time after surgery as well as with associated donor-site morbidity. Therefore, they prefer much more simple techniques. The objective of this study is to evidence that skin traction technique is a simple, short term, useful, and good option for closing open wound complex defect which needs the reconstruction with large flap.Methods: Skin traction techniques were applied to ten patients who had large complex defects in our clinic between March 2020 and March 2021. Patient’s data including demographic characteristic, comorbidities, causes of defects, anatomic localization of defects, size of defect, time of closure defect, time interval of tightening suture, number of tightening sutures, time of staying in hospital, general complication was recorded.Results: The study included 8 males and 2 females. The average age of patients was 42.8 years ranging from 22 to 60. The size of defects ranged between 8x5 cm and 18x10 cm with an average of 11.7x7.2 cm. The average duration of follow-up was 6 months. After 3 months, we evaluated subjectively quality of skin thickness, mobility, and colour. Skin was thinner and less mobile in the areas that were reconstructed with graft when compared with skin traction territories where the colour of skin was also normal in the cases with skin defect which was repaired by primarily closure after skin traction. All patients were satisfied with results. Complications such as skin necrosis at the traction site and hematoma were not observed. Superficial wound infection was seen in one patient, and it was resolved with antibiotherapy.Conclusions: We suggest using the traction suture technique for complex defects as an easy, cheap, and short-time procedure to reconstruct large and complex skin defects especially in recipient vessel problems, cases suffered from flap failure, patients with comorbidities and special conditions (for example, during the COVID-19 pandemic).

Double Frost Suture Technique for Simultaneous Skin Grafting of the Upper and Lower Eyelids.

The double Frost suture is a useful supplement to the reconstruction of ipsilateral upper and lower eyelid defects with full-thickness skin grafts. This technique involves silk traction sutures that overlap the upper and lower eyelids to place them on maximal stretch after placement of 2 full-thickness skin grafts. It has the added benefit of protecting the cornea and compressing both grafts under 1 bolster. The authors illustrate this technique in 2 pediatric cases-a congenital melanocytic kissing eyelid nevus and a periocular burn. Each case resulted in large upper and lower anterior lamellar defects, which were reconstructed with supraclavicular and retroauricular free skin grafts. The double Frost sutures counter vertical cicatricial forces during graft healing, obviating the need for staged procedures. Both described cases resulted in excellent graft survival with minimal contracture.

The Use of the Comma Sign and Tissue for Recognition, Reduction, and Stability During Arthroscopic Repair of Combined Anterosuperior Cuff Tears

Background: The comma sign is a useful marker for combined retracted supraspinatus and subscapularis tears. It was first described by the group of Burkhart as a “composite ligamentous structure” of the rotator interval attached to the retracted subscapularis. However, Neyton and coworkers suggested that the ruptured superior part of subscapularis is pulled upward by supraspinatus retraction. This video illustrates the value of “comma” recognition for reduction and repair stability. We feel that the comma tissue can be a composition of rotator interval ligaments with or without superior subscapularis contribution depending on an associated cleavage tear. Indications: Patients with retracted anterosuperior tears, unless muscle quality is poor (Goutallier classification ≥3). Understanding of the comma tissue is difficult but of crucial importance to assess complex anterosuperior cuff tears for reduction and repair with stability by maintaining and integrating this comma link into the repair construct. Technique Description: Arthroscopic setup includes beach chair position, armholder, cerebral saturation monitoring (target mean arterial blood pressure of about 70 mm Hg). Previously described circumferential portals were used for a repair with a double row construct (4 medial anchors: 2.5 for subscapularis; 1.5 for supraspinatus) and 2 lateral anchors. The superior boarder of subscapularis as well as the retracted capsular layer of supraspinatus was reduced and fixed using a lasso loop technique. Key stages are (1) tendon manipulation with 2 traction sutures; (2) tendon release; (3) comma reduction; (4) footprint preparation (burr, microfracture); (5) retrograde suture passing; (6) knot tying, knotless lateral row; and (7) a close surgeon to physiotherapist rehabilitation link (6 weeks passive to 90°, no resistance training for 3-6 months). Results: Senior author’s (S.B.) series: 32 anterosuperior tears over 4 years (mean age: 62 years, 48-73 years), minimum follow-up 1 year showed good results (mean SSV: 85% [preop. 35%], range: 40%-95%; mean Constant: 82 [preop. 30], range: 40-90). One major complication (cutibacterium infection; brick layer; workers compensation; invalidity demand; Constant/Subjective Shoulder Value both 40) and minor temporary stiffness at 3 months (8 patients; 22%). Conclusion: Adequate reduction and comma integration into a solid repair construct, as well as responsible rehabilitation surveillance, deliver successful results after technically intricate anterosuperior repairs.

Thoracoscopic intraoperative esophageal close technique for long-gap esophageal atresia.

Long-gap esophageal atresia (EA) remains a challenging operative procedure. Several techniques have been reported to resolve the problem of distance between the proximal and distal esophagus. We report a thoracoscopic intraoperative esophageal close technique for long-gap EA. A female neonate was born at 39 weeks of gestation with long-gap EA (five vertebrae). The patient underwent thoracoscopic esophageal anastomosis after esophageal elongation. Careful dissection of the proximal and distal esophagus was performed; however, the distance between them was still long. Extra-thoracic traction sutures were placed at the upper esophagus. Then, a Neraton catheter was inserted trans-orally and the upper esophagus was pushed and opened. An internal traction suture was placed between the Neraton catheter and lower esophagus. The gap between the proximal and distal esophagus could be approximated by pulling the Neraton catheter. Esophageal anastomosis was performed successfully. Our thoracoscopic intraoperative esophageal close technique was simple and useful.

A Clip-with-Line Traction Suture Method for Closing Mucosal Defects after Endoscopic Submucosal Dissection.

Endoscopic submucosal dissection (ESD) is a technically difficult endoscopic procedure for treating gastrointestinal diseases. Procedure time is longer, and complications such as mucosal defects, intraoperative perforation, and bleeding occur frequently. Here, to solve these problems, we described the clip-with-line traction suture method that applied and performed for closing mucosal defects after ESD in three representative cases.

The effects of laser displacement on femtosecond laser-assisted conjunctival autograft preparation for pterygium surgery.

AimsTo evaluate the effects of no-suction femtosecond laser (FSL) stability on conjunctival autograft (CAG) dissection in pterygium surgery.MethodsProspective analysis of 35 eyes from 34 subjects who underwent femtosecond laser-assisted pterygium surgery with the Ziemer Z8 laser (Ophthalmic Systems AG, Switzerland). Intraoperative absolute FSL displacements were measured and correlated with the duration and ease of CAG peel, CAG thickness, measured with intraoperative optical coherence tomography, and deviation from intended graft thickness.ResultsThe median absolute FSL displacement was 22 μm (interquartile range [IQR] 14.7 to 60.8), while median vertical FSL displacement was 14.7 μm (IQR 7.3 to 44) and median horizontal FSL displacement was 22.0 μm (IQR 14.7 to 44). 65.7% had a grade 1 peel, 11.4% had grade 2 peel, 14.3% had grade 3 peel and 8.6% had grade 4 peel. The median duration of CAG peel was 5.4 seconds (IQR 3 to 21.4). The median CAG thickness was 69 μm (IQR 60.3 to 78.5), and the median deviation from targeted graft thickness was 9 μm (IQR 1 to 16). Eyes with more difficult peels and longer duration of CAG peels had significantly greater vertical FSL displacements (p = 0.04 and 0.02 respectively), but not horizontal displacement, age, ethnicity, CAG thickness or deviation from original thickness, compared to those with better quality and shorter duration peels. 1 eye (2.9%) had an incomplete CAG peel with a buttonhole and 2 eyes had graft tears (5.7%).ConclusionMicro-displacements during the suction-free CAG preparation are common but they did not affect the quality of the CAG peel, duration of peel, or CAG thickness. However, vertical globe displacement during FSL-assisted CAG creation was significantly associated with a more difficult and longer CAG peel duration. This highlights the importance of the cornea traction suture fixation to ensure stability of the eye during FSL application.

A prospective, randomised study of the effect of fixation sutures during phacotrabeculectomy on intraocular pressure and incidence of ptosis

We investigated the effects of different intraoperative eyeball fixation techniques (superior rectus muscle suture [MS] and traction suture at the corneal limbus [CS]), on intraocular pressure (IOP) and the incidence of ptosis after phacotrabeculectomy. Forty-one eyes with different glaucoma types which qualified for phacotrabeculectomy were included. Twenty-three and eighteen patients were included in the CS and MS groups, respectively. The IOP, best-corrected visual acuity (BCVA), and margin reflex distance were assessed preoperatively and 3, 6, and 12 months post-operatively. Preoperatively, the mean IOPs (± standard deviation) in the CS and MS groups were 23.6 ± 7.3 mmHg and 24.3 ± 6.6 mmHg (p > 0.05), respectively. At 3 and 6 months post-surgery, the mean IOPs were significantly lower in the CS group than in the MS group: 13.9 ± 3.0 mmHg vs. 17.7 ± 3.5 mmHg (p = 0.001), and 13.9 ± 4.9 mmHg vs. 17.2 ± 3.5 mmHg (p = 0.005), respectively (mean difference: 3.9, 95% confidence interval 1.7–6.1). At 12 months, the mean postoperative IOPs were 15.2 ± 3.5 mmHg and 14.9 ± 3.6 mmHg in the CS and MS groups, respectively (p > 0.05). At 6 months, the BCVAs were 0.91 ± 0.15 and 0.71 ± 0.3 (p = 0.029) in the CS and MS groups, respectively; BCVAs were 0.91 ± 0.15 and 0.71 ± 0.3 (p = 0.029) in the CS and MS groups, respectively; the difference was non-significant 12 months post-surgery (0.78 ± 0.32 vs. 0.74 ± 0.30, p = 0.553). Postoperative ptosis was observed in 4 (17%) and zero patients in the CS and MS groups, respectively, but the difference was not statistically significant (p = 0.118). The study was not powered sufficiently to detect statistically significant changes in exploratory endpoints. The study was not powered sufficiently to detect statistically significant differences between groups in exploratory endpoints.

Robotic central hepatectomy: technical tips and tricks

Purpose: Minimal invasive (MI) central hepatectomy is considered a technical complex procedure. The robotic approach could provide benefits over traditional laparoscopy, thanks to 3D visualization, endowrist technology and tremor filtration. Based on three different cases, this video aims to demonstrate technical tips and tricks for robotic central hepatectomy. Methods: The cases consisted of an anatomic segment 4 resection for two hepatocellular carcinoma (HCC), a MI resection of segment 5 and part of segment 8 for a solitary colorectal liver metastasis, and a MI resection of segment 4, 5 and 8 for a mixed cholangiocarcinoma and HCC. Results: A series of tips and tricks are proposed. (1) Installation: supine anti-Trendelenburg position with four robotic ports and an AirSeal port. (2) Exposure: optimal instrument and gauze placement, and application of a percutaneous traction suture to facilitate resection of segment 8 lesions. (3) Intraoperative ultrasound: demarcation of the tumor margins with monopolar scissors. (4) Pringle maneuver: an extracorporeal method with an umbilical tape encircling the hepatoduodenal ligament inserted in a chest tube, versus an intracorporeal method based on the Huang loop technique with application of a vascular bulldog clamp instead of a locking clip to apply tension, allowing to Pringle intermittently. (5) Parenchymal transection: in both healthy and cirrhotic liver tissue the combination of bipolar sealing device, Kelly-crush technique with fenestrated bipolar forceps, and monopolar scissors, proved to be highly efficient. (6) Hemostasis: achieved by preoperative hypovolemic phlebotomy with blood salvage, locking polymer clips, barbed resorbable sutures, hemostatic matrix, fibrillar absorbable haemostat and fibrin sealant patch. Operative time was 198 ± 12.6 minutes. The Pringle maneuver was applied 52.3 ± 8.7 minutes. Blood loss was 60 ± 26.5 cc. No intraoperative complications were encountered. R0-resection was obtained in all patients. The postoperative course was uneventful. Discharge happened on postoperative day 3 ± 1. Conclusion: A systematic approach of robotic central hepatectomy provides a technically feasible and adequate alternative for laparoscopy.

Laparoscopic assisted extracorporeal ovarian harvest: A novel technique to optimize ovarian tissue for cryopreservation in young females with cancer

BackgroundAdvances in pediatric cancer therapy have improved the long-term survival for many children with cancer. The awareness of quality of life aspects, specifically fertility preservation, has become a reality for many of these families and children. Ovarian tissue cryopreservation has emerged as an available fertility option for young females with cancer. Safe and effective removal of ovarian tissue in these girls is paramount. We report a laparoscopic assisted extracorporeal ovarian harvest technique that achieves this goal. Operative techniqueWe place a 5 mm port at the umbilicus and in the right lower quadrant. Under laparoscopic guidance we place a 12 mm port in the left suprapubic area. Utilizing the 12 mm port site a monofilament traction suture is placed through the left ovary. The traction suture is used to translocate the ovary to an extracorporeal position via the 12 mm port site. Ovarian tissue is then excised utilizing standard surgical technique with the scalpel. Hemostasis is obtained and the capsule is closed with a running absorbable suture. The ovary is placed back in its native position laparoscopically. ConclusionsThe use of this extracorporeal ovarian harvesting technique is a safe and effective method to optimize removal and minimize tissue injury. Utilization of this technique, may have potential benefit to the young female with cancer.

Expanded use of transconjunctival orbitotomy in management of different orbital tumors at different locations.

To assess the surgical outcomes of transconjunctival approach in management of different orbital tumors at different locations. This prospective, non-comparative, clinical interventional study was conducted in the period between March 2017 and January 2020 and included 61 patients with histologically proved orbital tumors. In all cases, a conjunctival incision near the fornix was made depending on the tumor location as revealed by CT or MRI. A traction suture was applied to one or two relevant recti muscles to guide the globe toward the desired direction. Blunt orbital dissection was made toward the tumor until exposing its anterior surface. The procedure was considered successful if the predetermined decision (total excision with improved clinical manifestations for benign and biopsy for diagnosis in malignant tumors) was achieved without causing permanent complications. The procedure was considered a failure if the predetermined decision was not achieved or if permanent complications developed. The patients were divided into: Group A of 47 patients (77.05%) with benign tumors and Group B of 14 patients (22.95%) with malignant tumors. The overall success rate of the approach was 98.36% (60 out of 61 patients), while failure occurred in one case (1.64%). The transconjunctival orbitotomy is an excellent approach to manage different tumors at different orbital locations with rapid recovery and maximum cosmetic results. It is the only approach that can access intra-conal, mid-orbital tumors whatever their relation to the optic nerve without crossing it.

SURGICAL TACTICS OF SAVING THE NATIVE ESOPHAGUS IN CASE OF LONG GAP ESOPHAGEAL ATRESIA

Introduction. The absence of a single surgical tactic for a long gap esophageal atresia (LGEA) treatment as well as frequent unsatisfactory results of applying existing treatment methods urge searching and implementing of a new surgical approach to remediation of malformation. Objective. To optimize surgical treatment of LGEA and provide preservation of native esophagus by elongating and pouches growth inducting. Materials and methods. 6 clinical cases of patients with LGEA who had been treated in National children specialized hospital “Okhmatdyt” during 2018-2019 were analyzed. All patients received staged malformation remediation by elongating of esophagus pouches with traction sutures with further formation of anastomosis. Results. 6 patients with LGEA were surgically treated by esophageal lengthening using the Foker process. The duration of traction varied from 6 to 19 days, the average daily distance of traction of each segment was from 2,4 to 4,8 mm. Segment growth efficiency was observed by diagnostics of metal clips positioning at the ends of esophagus segments on X-ray, or esophagography. In all 6 cases the application of dozed staged traction resulted in esophagus lengthening with elimination of gap from 0-1,0 sm, so that anastomosis of native esophagus was accomplished with the further oral feeding. Conclusions. The method of growth induction allows to overcome a long gap between segments of the atretic esophagus, create conditions for the formation of anastomosis and preserve own esophagus with the restoration of age-related oral nutrition. The concept of induction of esophageal growth eliminates or reduces the use of intestinal plastic of esophagus. The Foker process is an organ-preserving method and is an alternative to operations with loss of an esophagus.

Traction Suture Technique for Correction of Caudal Septal Deviation.

Correcting the caudal septum deviation is one of the most difficult parts of the septoplasty. The aim of the present study was to evaluate the efficiency and usefulness of traction suture method in caudal septum deviations. Medical records of 35 patients who underwent endonasal septoplasty using traction suture method for caudal septum deviation in August 2017-February 2019 period were studied retrospectively. Preoperative nasal obstruction symptom evaluation (NOSE) scores of the patients were compared with postoperative sixth month NOSE scores. Besides, preoperative nasal examination findings of the patients were compared with the ones in postoperative period. Average age of the 35 patients (9 women and 26 men) in the study was 26.3 ± 10.1 years. Postoperative observations revealed that a straight septum was achieved in 31 patients (91.1%). Average pre- and postoperative NOSE scores were 85.1 ± 20.4 and 22.4 ± 4.2, respectively (P < 0.0001). Nasal obstruction was "much improved" in 19 patients (54.2%) and "improved" in 12 (37.1%), while 4 patients (8.6%) reported "no change." None of the patients developed postoperative complications. Traction suture method is a safe, efficient, and useful option to be used by surgeons for caudal septum deviation.

Cervical traction suture technique during large loop excision of the transformation zone increases complete lesion excision

PurposeA surgical technique was developed in the past by our group to reduce the rate of inadvertent complications. It was then seemed that it also increased the rate of complete lesion excision. The objective of the study was to evaluate the effectiveness of a cervical traction suture technique in increasing the prevalence of complete lesion excisions and reducing the incidence of unintended injuries to adjacent tissues during large loop excision of the transformation zone (LLETZ). Basic proceduresA retrospective cohort study, including all consecutive patients who underwent LLETZ between January 2016 and June 2018, at the outpatient Colposcopy clinic of a general hospital in Galilee Medical Center. We divided patients into two groups based on whether their LLETZ utilized the cervical traction suture technique. We compared these two groups using an independent-samples t test, and we compared the study-specific proportions to those reported in the literature using the proportion test. Main findingsA total of 66 patients were included in the analysis; 33 had undergone LLETZ with a traction suture, and 33 had undergone LLETZ without a traction suture. The prevalence of complete lesion excision was 93.3 % among patients undergoing LLETZ with a traction suture and 72.7 % among those without a traction suture (p = 0.04). The incidence of unintentional injuries to adjacent organs was 12.1 % in women with a traction suture and 18.2 % in women without a traction suture (p = 0.73). Principal conclusionsUsing a cervical traction suture along with LLETZ can increase the rate of complete lesion excision and may reduce the prevalence of unintended injuries.

The Unspoken Question!

The Unspoken Question!

Observations on opening and closing the abdominal incision for cytoreductive surgery using a self-retaining retractor to reduce the incidence of incisional hernia

BackgroundCytoreductive surgery for resection of peritoneal metastases requires an incision from the xyphoid process to the pubic rami. Laboratory and clinical data from randomized trials have shown that small (0.5–1.0 cm) bites of a running suture closely spaced (0.5 cm) through an isolated midline fascia results in the lowest incidence of incisional hernia. MethodsManuscripts were used to formulate criteria for optimal closure of a long midline abdominal incision. Using these conclusions as a starting point, surgical technology to achieve an optimal wound closure were formulated. ResultsA fixed retractor was placed prior to performing an abdominal incision. Skin traction sutures elevate the skin and subcutaneous tissue to facilitate fascial incision directly through the linea alba. Peritoneum and preperitoneal fat beneath the posterior rectus sheath are resected. Separations of the anterior and posterior rectus sheath are repaired prior to fascial closure. When closing the incision, a running suture of closely spaced small bites is used to bring the fascial edges together in the absence of excess tension. During closure of the fascia exposure of the linea alba with the skin traction sutures facilitates accurate placement of fascia only sutures. ConclusionsOptimal exposure of abdominal wall structures while opening and closing a long midline abdominal incision will minimize the incidence of incisional hernia. A fixed retractor and skin traction sutures are required.

Endophthalmitis after strabismus surgery: incidence and outcome in relation to age, operated eye muscle, surgical technique, scleral perforation and immune state.

PurposeIdentify risk factors for endophthalmitis after strabismus surgery (EASS) and relate these to incidence and outcome.MethodsOphthalmologists, who had operated, diagnosed or treated EASS, completed a case record form with 71 questions in six domains: Preoperative, Surgery, Perforation, Postoperative, Outcome and Experts’ opinion. To estimate the age‐specific incidence per number of strabismus operations in the Netherlands during 1994‐2013, the age distribution of Dutch cases was compared with the age‐specific rates of strabismus surgery in the Dutch Registry of Strabismus Operations and with population data. Exploratory data analysis was performed. The immune state was evaluated in six patients. Five enucleated eyes were studied histopathologically.ResultsNone of the 26 patients (27 eyes with EASS) were between 9 and 65 years old, except for one patient with retinal haemorrhage followed by endophthalmitis. In the Netherlands during 1994‐2013, the rate of EASS was approximately one per 11 000 strabismus operations, but one per 4300 for children aged 0–3 and one per 1000 for patients 65 and older. Endophthalmitis was diagnosed on postoperative day 1–4 in children aged 0–3. In all 15 children aged 0–5, the 16 affected eyes were phthisical, eviscerated or enucleated. The involved eye muscle had been recessed in 25 of 27 cases. It was a medial rectus in 15 of 16 children aged 0–6. It was a lateral (6), inferior (2) or medial (1) rectus in elderly. Scleral perforation went unnoticed in all children (no record in three) and in two of seven elderly (no record in two). Histopathology showed transscleral scarring compatible with scleral perforation in four patients but, in a two‐year‐old girl who had EASS together with a transient medial rectus palsy, the sclera underneath the former suture tract was not perforated but did contain the long posterior ciliary artery.ConclusionsEndophthalmitis after strabismus surgery (EASS) affects children and elderly, with a grave outcome in young children. It occurs after recession of the medial rectus muscle in children, and it may occur without scleral perforation. Age and perforation are key determinants that interact with other factors that determine the occurrence and fulminance of EASS.