Traditional Open Procedures Research Articles

Percutaneous Distal Metatarsal Mini-Invasive Osteotomy: Comparison Between Standard vs Modified Intraosseous Approach: A Cadaveric Study

Category:Midfoot/ForefootIntroduction/Purpose:Minimally invasive surgery (MIS) of the forefoot has gained popularity as an alternative to traditional open procedures for the treatment of metatarsalgia and hammertoe deformity. Distal metatarsal mini-invasive osteotomy (DMMO) is an extraarticular osteotomy done in a percutaneous manner, with minimal soft tissue dissection that permits elevation as well as shortening. However, there is concern for damage to vital structures due to lack of direct visualization. The objective of the study was to evaluate the structures at risk in standard versus modified DMMO.Methods:11 thawed fresh-frozen cadaveric specimens underwent minimally invasive DMMO using both the standard and modified approach. The standard technique was performed by moving the burr in a circular motion with an angle of 45° (right- handed surgeon), which cut sequentially the left, plantar, right and dorsal cortices. It was compared to a modified intraosseous technique requiring less wrist supination while remaining intraosseous. After completion of the procedures, the cadavers were fully dissected and analysed to identify unintentional injury to soft tissue structures and to verify if cuts were completely extraarticular and performed with proper angulation.Results:In the standard group the most commonly injured structures were the metatarsal joint capsules (MJC) (27%), extensor digitorum longus (EDL) (18%), and extensor digitorum brevis (EDB) (9%). The modified intraosseous group demonstrated injury to the EDL (27%), while MJC (0%) and EDB (0%) were not damaged. Distances between osteotomies and structures were 6.08 +- 3.99 mm from the dorsal metatarsal head articular surface (DMHAS), 4.85 +- 2.45 mm from EDB and 0.76 +- 1.72 mm from the EDL in the standard group and 9.92 +- 3.42 mm from the DMHAS, 4.71 +- 3.24 mm from EDB and 1.24 +- 1.84 mm from the EDL in the modified group. Statistically significant difference was found among osteotomy site and DMHAS (p=0.02).Conclusion:The most frequently injured structure was the EDL tendon with both DMMO techniques used. Intra-articular positioning of the osteotomy was more frequently observed in the standard technique. There was also a statistically significant difference between the distance of the osteotomy site and the dorsal metatarsal head articular surface when comparing the standard group and the modified group. Overall, it appears that the modified method could be a safer, less complex alternative to the standard DMMO technique, especially for the inexperienced surgeons.

Image-guided, surgical robot-assisted percutaneous puncture of the foramen ovale and foramina stylomastoideum: a cadaveric study.

Image-guided, surgical robot-assisted percutaneous puncture of the foramen ovale and foramina stylomastoideum: a cadaveric study.

Functional outcome of proximal 1/3rd, distal 1/3rd and diaphysial tibial fractures in adults operated with expert tibial nailing

<p class="abstract"><strong>Background:</strong> Fractures of the tibial shaft are increasing due to high velocity trauma and industrialisation. Not only they are common but also difficult to treat. Until recently surgeons had to rely on non-operative treatment, V nailing, plates and screws and external fixator but they had their drawbacks like prolonged immobilisation infection, delayed union and non-union. Numerous modifications in nail and screw design have led to development of the expert tibial nail. Multidirectional interlocking screws ensure that alignment can be well maintained and stability preserved in short proximal or distal tibial segments.</p><p class="abstract"><strong>Methods:</strong> 30 patients were admitted and operated during September 2014 to September 2016 in Mamata general hospital Khammam. All patients were evaluated with Klemm Borner’s criteria and complications following surgery.<strong></strong></p><p class="abstract"><strong>Results:</strong> 87% of patients achieved good or excellent results, fair results were obtained in 3 (10%) patient and poor result in one (3%) patient. 2 (6%) patients had malunion, 2 (6%) patients had delayed union, 1 (3%) patient had deep infection led to implant failure.</p><p class="abstract"><strong>Conclusions:</strong> Intramedullary nailing is a safe and effective technique for the treatment of tibial metaphyseal fractures. It avoids the additional soft-tissue dissection associated with traditional open procedures as well as the complications associated with external fixators. Expert tibial nail can give excellent functional and clinical results. Complications such as failure of the bone-implant construct or post-operative malallignment are avoidable if careful pre-operative planning is allied with meticulous surgical technique.</p>

Robotic-assisted harvest of latissimus dorsi muscle flap for breast reconstruction: review of the literature.

Robotic-assisted surgery continues to gain ground over conventional surgical methods, due to reported better results regarding the aesthetic outcome and the decreased percentage of complications. Although latissimus dorsi flap harvesting for breast reconstruction has been already used for several years, a plethora of serious complications has been reported. Recently, minimally invasive surgical approaches, such as robotic-assisted technique, have been suggested with conflicting outcomes to overcome technical difficulties. Therefore, the literature review was conducted regarding robotic-assisted harvesting of the latissimus dorsi flap for breast reconstruction. A narrative review of the contemporary literature was performed in the PubMed database for the use of robotic-assisted surgery of latissimus dorsi muscle flap harvesting for breast reconstruction. Appropriate search terms were used, and specific inclusion and exclusion criteria were applied. Five studies met the inclusion criteria. A total of 32 cases of robotically assisted harvesting of pedicled latissimus dorsi muscle flap for implant-based breast reconstruction have been identified. All flaps were successfully harvested without converting in the traditional open procedure. There were no significant postoperative complications, expect from few cases of postoperative seromas, which were conservatively managed. Additionally, all patients were satisfied with their postoperative cosmetic outcome. The robotic-assisted harvesting technique of the latissimus dorsi flap for breast reconstruction is safe and comparable to the conventional methods. Reduced hospital stays and superior aesthetic outcome are the main advantages, while total cost and the difficulty of reaching the learning curve plateau are the main concerns regarding this modern and minimally invasive surgical approach.

Does obesity affect long-term outcomes of extreme lateral interbody fusion with posterior stabilization?

Background ContextObese patients can pose significant challenges to spine surgeons in lumbar fusion procedures. The increased risk of complications has led surgeons to be wary in pursing operative interventions in these patients. Since the advent of minimally-invasive techniques in lumbar fusion, surgeons are turning to these procedures in an attempt to minimize operative time, blood loss and overall cost. With an increased proportion of obese patients in the population, it is imperative to understand the long-term outcomes in these minimally-invasive approaches. PurposeThe purpose of this study was to evaluate the long-term safety and efficacy of extreme lateral interbody fusion (XLIF) in the obese. Study Design/SettingRetrospective cohort study. Patient SampleA total of 115 patients (53 nonobese and 62 obese) who underwent XLIF with a minimum of 5-year follow-up. Outcome Measures(1) Patient reported outcome scores: Visual Analog Scale (VAS) for back pain, Oswestry Disability Index (ODI), (2) Reoperation rate, (3) Pelvic incidence (PI)- Lumbar lordosis (LL) mismatch correction, (4) Graft subsidence and fusion rate MethodsA retrospective review was performed to identify patients who underwent XLIF with percutaneous posterior stabilization since 2007 with a minimum follow-up of 5 years. Demographics including BMI were recorded and patients were subdivided into 2 cohorts: nonobese (BMI <30 kg/m2) and obese (BMI ≥30 kg/m2). Functional outcomes were assessed by comparing pre- and postoperative VAS and ODI scores. Reoperation rates were compared between cohorts. PI-LL mismatch was calculated from both pre- and postoperative radiographs. Rates of graft subsidence and fusion were measured at final follow-up. ResultsA total of 115 consecutive patients were included (53 nonobese and 62 obese) with a mean follow up of 95.3 months. Mean BMI was 25.3 in the nonobese group and 35.3 in the obese group (p<.001). There were more females in nonobese cohort. VAS scores decreased by a mean of 5.7 in the nonobese cohort, and 5.4 in the obese cohort (p=.213). ODI improvement was also similar between the groups. 5.6% of nonobese patients required reoperation compared to 9.6% of obese patients (p=.503). Graft subsidence rates at final follow-up were 5.66% and 8.06% for the nonobese and obese groups, respectively (p=.613). Rates of successful fusion were 96.23% and 98.39% for the nonobese and obese groups, respectively (p=.469). Both cohorts achieved a similar proportion of PI-LL mismatch correction, 85% in obese versus 78% in nonobese patients (p=.526). ConclusionObese patients have similar surgical outcomes to nonobese patients with respect to functional outcome scores, reoperation rates, graft subsidence and correction of PI-LL mismatch after long-term follow-up. With similar outcome and reoperation profiles, minimally-invasive approaches to the spine, such as XLIF, may be an acceptable alternative to traditional open procedures in obese patients.

The Utility of Prolonged Prophylactic Systemic Antibiotics (PPSA) for Subfascial Drains After Degenerative Spine Surgery.

Retrospective cohort study. The aim of the current investigation was to evaluate the impact of prolonged prophylactic systemic antibiotics (PPSA) on the development of surgical site infection rate (SSIR) in degenerative spine surgery. Surgical drains are utilized postoperatively in posterior spine surgery to help minimize the risk of seroma formation. Prophylactic antibiotics while drains are in place are frequently used to reduce SSIR, though the practice remains controversial. We performed a single center, retrospective review of all patients that underwent posterior spinal surgery for cervical and lumbar degenerative pathology over a 3.5 year period (January 2016-July 2019). Patients underwent a traditional open posterior midline procedure with postoperative placement of a subfascial surgical drain. Antibiotics were administered for the duration of the drain (PPSA group) or for 24 hours postoperatively (non-PPSA group). The number of surgical site infections, organism, and Clostridium difficile infections was recorded. Three hundred thirty six patients were identified, 168 patients in the PPSA group and 168 in the non-PPSA groups. The overall SSIR was 5.36% (18/336). The SSIR for the non-PPSA and PPSA groups were 7.14% (12/168) and 3.57% (6/168), respectively (P = 0.146). While difference of SSIR between the groups was two-fold, it was not statistically significant. For the non-PPSA and PPSA groups, the SSIR for cervical (5.95% [5/84] vs. 2.38% [2/84], P = 0.443) and lumbar (8.33% [7/84], vs. 4.76% [4/84], P = 0.535) regions were not significantly different. C. difficile cases in the PPSA and non-PPSA groups were 1/168 and 0/168 respectively (P = 1.00). Our series demonstrate a two-fold reduction of SSI with implementation of PPSA regimen. This benefit was demonstrated separately for both cervical and lumbar regions. Randomized trials and increase in sample size are warranted to elucidate the significance of PPSA in posterior spinal surgery.Level of Evidence: 3.

The Impact of the Aging Population on Surgical Diseases

The portion of the population comprised by those aged 65 years and older is the fastest growing age group. With the aging of Americans, so goes the age of a surgeon’s patients. It is also well established that with aging, the incidence of various diseases also increases. Thus, more surgical care will be consumed by the elderly. The cost of care however will be greater for geriatric patients when compared to younger patients due to the greater incidence of comorbidities in the elderly. The surgical community will need to develop new protocols for the perioperative care of these frail patients in order to provide safe care with acceptable morbidity and mortality rates. Over the past 5 years, there have been notable changes in the surgical management of geriatric patients. Increased evidence in several surgical specialties supports that minimally invasive techniques for traditional open procedures improve outcomes. Additional knowledge regarding the effect of aging on organ function has led to improved stratification and preoperative preparation of patients prior to surgery. An example of this is the establishment of specific triage criteria for geriatric trauma patients. These changes have resulted in reduced morbidity and mortality rates. The elderly form a large portion of surgical patients, and this portion will continue to grow as life expectancy improves. Surgeons must adapt to this changing environment to provide optimal care to geriatric patients.

Microendoscope-Assisted Versus Open Posterior Lumbar Interbody Fusion for Lumbar Degenerative Disease: A Multicenter Retrospective Cohort Study.

Background and objectives: Minimally invasive surgery has become popular for posterior lumbar interbody fusion (PLIF). Microendoscope-assisted PLIF (ME-PLIF) utilizes a microendoscope within a tubular retractor for PLIF procedures; however, there are no published reports that compare Microendoscope-assisted to open PLIF. Here we compare the surgical and clinical outcomes of ME-PLIF with those of open PLIF. Materials and Methods: A total of 155 consecutive patients who underwent single-level PLIF were registered prospectively. Of the 149 patients with a complete set of preoperative data, 72 patients underwent ME-PLIF (ME-group), and 77 underwent open PLIF (open-group). Clinical and radiographic findings collected one year after surgery were compared. Results: Of the 149 patients, 57 patients in ME-group and 58 patients in the open-group were available. The ME-PLIF procedure required a significantly shorter operating time and involved less intraoperative blood loss. Three patients in both groups reported dural tears as intraoperative complications. Three patients in ME-group experienced postoperative complications, compared to two patients in the open-group. The fusion rate in ME-group at one year was lower than that in the open group (p = 0.06). The proportion of patients who were satisfied was significantly higher in the ME-group (p = 0.02). Conclusions: ME-PLIF was associated with equivalent post-surgical outcomes and significantly higher rates of patient satisfaction than the traditional open PLIF procedure. However, the fusion rate after ME-PLIF tended to be lower than that after the traditional open method.

Minimally Invasive Spine Surgery: Techniques, Technologies, and Indications.

Over the past few decades, interest in minimally invasive spine surgery (MISS) has increased tremendously due to its core principle of minimizing approach-related injury while providing outcomes similar to traditional open spine procedures. With technical and technological advancements, MISS has expanded its utility not only to simple spinal stenosis, but also to complex spinal pathologies such as metastasis, trauma, or adult spinal deformity. In this article, we review the techniques and technology in MISS and discuss the indications, benefits, and limitations of MISS.

Emergency laparoscopic surgery during COVID-19: What can we do and how to do it safely.

Emergency laparoscopic surgery during COVID-19: What can we do and how to do it safely.

Financial impact of adapting robotics to a thoracic practice in an academic institution.

In the current healthcare environment there is increasing pressure to deliver high quality care to more people at less cost. Robotic assisted thoracic surgical procedures (RATS) have been shown by some to be more expensive than conventional endoscopic or open surgery. We initiated this study to assess the financial impact of RATS compared to robotic non-thoracic surgery in an academic institution. A retrospective study was performed for all patients who underwent any robotically assisted surgical procedure at Temple University Hospital (TUH) in fiscal year 2015. Surgical volume, operative time, length of stay (LOS), case mix index (CMI), direct and indirect costs, hospital charges, surgical charges, contribution margin (CM) and net margin (NM) were collected for the thoracic surgery service in addition to other services which performed more than 20 robotic cases a year. We analyzed the data according to the following strategy: (I) financial performance for both inpatient and outpatient robotic procedures for the entire hospital; (II) compared financial data for robotic and non-robotic surgeries in the thoracic surgery division; (III) compared thoracic surgery data with the STS database for the same time period in order to calculate any potential cost saving (PCS). In FY15, a total of 696 robotic procedures were performed by the various services at TUH with a mean of 58 cases each month. Although CM was highest for cardiovascular surgery, the highest NM was by thoracic surgery. Despite having the highest volume and a positive CM, the mostly outpatient urology service showed a negative NM in FY15. A CMI-adjusted comparison on 208 of the 589 robotic procedures where there was a comparable group of inpatients who had open procedures, the mean direct cost for non-robotic procedures was $6,239, 9% less than for robotic procedures. The mean total cost for non-robotic procedures was only 3.64% ($435) less than that for robotic procedures ($11,502 vs. $11,937). When compared with the UHC expected LOS, the robotic group had a lower LOS while the non-robotic group had a higher LOS. The mean total direct costs were $3,510 less for the robotic procedures ($16,502 vs. $20,012). When compared to similar cases reported to the STS in FY 2015, the length of stay, conversion rate, transfusion rate, post-operative complications and OR time compared favorably. Using calculations based on published data, the potential cost savings are in the 1 to 2 million dollar range compared to traditional endoscopic or open procedures reported to the STS. High acuity services such as Thoracic Surgery drive higher CM per case as long as variable costs especially LOS are kept low. Procedures with lower CMI may not provide a high enough CM to offset the fixed and variable costs. Robotic surgical cases performed in the outpatient setting may incur significant losses as the reimbursement does not cover the direct costs. Hospitals should preferentially allocate robotic resources to inpatient procedures with higher CMI and work to decrease overall LOS.

Clinically Significant Visual Deficits after Laser Interstitial Thermal Therapy for Mesiotemporal Epilepsy

Background: Laser interstitial thermal therapy (LITT) has recently gained popularity as a minimally invasive surgical option for the treatment of mesiotemporal epilepsy (mTLE). Similar to traditional open procedures for epilepsy, the most frequent neurological complications of LITT are visual deficits; however, a critical analysis of these injuries is lacking. Objectives: To evaluate the visual deficits that occur after LITT for mTLE and their etiology. Method: We surveyed five academic epilepsy centers that regularly perform LITT for cases of self-reported postoperative visual deficits. For these patients all pre-, intra- and postoperative MRIs were co-registered with an anatomic atlas derived from 7T MRI data. This was used to estimate thermal injury to early visual pathways and measure imaging variables relevant to the LITT procedure. Using logistic regression, we then compared 14 variables derived from demographics, mesiotemporal anatomy, and the surgical procedure for the patients with visual deficits to a normal cohort comprised of the first 30 patients to undergo this procedure at a single institution. Results: Of 90 patients that underwent LITT for mTLE, 6 (6.7%) reported a postoperative visual deficit. These included 2 homonymous hemianopsias (HHs), 2 quadrantanopsias, and 2 cranial nerve (CN) IV palsies. These deficits localized to the posterior aspect of the ablation, corresponding to the hippocampal body and tail, and tended to have greater laser energy delivered in that region than the normal cohort. The patients with HH had insult localized to the lateral geniculate nucleus, which was ­associated with young age and low choroidal fissure CSF volume. Quadrantanopsia, likely from injury to the optic radiation in Meyer’s loop, was correlated with a lateral trajectory and excessive energy delivered at the tail end of the ablation. Patients with CN IV injury had extension of contrast to the tentorial edge associated with a mesial laser trajectory. Conclusions: LITT for epilepsy may be complicated by various classes of visual deficit, each with distinct etiology and clinical significance. It is our hope that by better understanding these injuries and their mechanisms we can eventually reduce their occurrence by identifying at-risk patients and trajectories and appropriately tailoring the ablation procedure.

Development and practice of laparoscopic surgery in a Nigerian tertiary hospital.

For the benefits of less postoperative pain, early recovery and discharge, and better cosmesis, laparoscopic surgery is rapidly gaining acceptance amongst surgeons as a better alternative to traditional open procedures. In January 2015, bookings for laparoscopic surgery became a more regular feature on our operation list. We reported the indications, management outcome, and challenges in patients who had laparoscopic surgery in our institution. This is to document the trends in our surgical practice. This is a descriptive study of 137 patients who had laparoscopic surgery for general surgical indications in our institution over a period of 5 years. Patients data as collected from the records department were evaluated for demographic characteristics, medical comorbidities, type of procedures done, and perioperative outcome. Data analysis was performed using Statistical Package for Social Sciences (SPSS). A total of 137 Patients had laparoscopic general surgery between January 2015 and December 2019. There were 48 males and 89 females with a male-to-female ratio of 1:1.9. The mean age of the patients was 38.8 ± 3.4 years (range 16-87 years). Laparoscopic cholecystectomy (35%) and laparoscopic appendicectomy (29.9%) were the most common procedures performed. Five (3.7%) cases were converted to open surgery. Superficial surgical site infection (5.8%) following laparoscopic appendicectomy was the most common postoperative complication. There was no 30-day postoperative mortality. Laparoscopic surgery is safe and can be applied to wide variety of general surgical conditions in developing countries. Minimal postoperative morbidity of laparoscopy is a major benefit to the patients.

Structures at Risk During Percutaneous Extra-Articular Chevron Osteotomy of the Distal First Metatarsal.

Background. Minimally invasive surgery of the forefoot has regained popularity as an alternative to traditional open procedures. Minimally invasive hallux valgus surgery has been shown to be effective and reproducible for the treatment of mild to moderate hallux valgus. The aim of this study is to identify vital structures that are at risk for iatrogenic damage while performing a minimally invasive distal chevron osteotomy due to limited direct visualization. Methods. Ten fresh-frozen below knee cadavers were used for this study. A minimally invasive distal chevron osteotomy and medial eminence resection with a 2.2 mm × 22 mm Shannon burr was performed on each cadaver. Each specimen was dissected to expose the potential structures at risk for injury during the procedure. Structures evaluated included the medial neurovascular bundle, first metatarsophalangeal joint capsule, extensor hallucis longus tendon, flexor hallucis longus tendon, abductor hallucis tendon, and the sesamoid apparatus. Results. Ten specimens were evaluated. The dorsal medial cutaneous nerve was directly injured in 5 of the 10 cadaver specimens and intact/uninjured in the remaining 5 specimens. The flexor hallucis longus, extensor hallucis longus, adductor tendon, sesamoid apparatus, and first metatarsophalangeal joint capsule were uninjured in all specimens. Conclusion. Minimally invasive chevron distal osteotomy and medial eminence resection has a high learning curve. The resection of the medial eminence may iatrogenically injure the dorsal medial cutaneous nerve. The incidence is higher in this study than prior reported cadaveric studies and may warrant extra care to protect vital structures.Level of Evidence: Level IV: Cadaver study.

Comparison of pedicle screw misplacement following open vs. percutaneous dorsal instrumentation after traumatic spinal fracture.

Dorsal stabilization is a frequently used procedure in the treatment of acute traumatic vertebral body fractures. Besides the traditional open surgical procedure, the percutaneous positioning of pedicle screws is now widely used. The aim of the current study is to compare pedicle screw misplacement following open vs. percutaneous dorsal instrumentation after traumatic spinal fracture of the thoracic and lumbar spine and to assess possible risk factors associated with pedicle screw misplacement. All patients who suffered a traumatic spinal fracture that were treated with dorsal stabilization in our level I trauma center in the period from 01/2007 to 03/2014 were included in this retrospective therapeutic cohort study. From 01/2007 to 06/2009, an open surgical procedure was used, and from 06/2009 to 03/2014, the percutaneous procedure was used for all types of fractures. Retrospectively, the positioning of every single pedicle screw was evaluated in the post-operative computed tomography scan and classified. Epidemiological data were also documented to compare the two treatment groups. A total of 491 patients with 681 vertebral body fractures were included. Of 733 pedicle screws placed during the open surgery procedure, 96.0% were within the safe zone. There was no significant difference compared with pedicle screws placed percutaneously (95.3% of 1884 screws). In all other categories, the number of misplaced pedicle screws also showed no differences between the two treatment groups. There is a positive correlation between pedicle screw misplacement and duration of the operation. Most pedicle screws are misplaced at the levels T12, L1 and T7, T8. The current study shows that percutaneous surgery using dorsal stabilization allows the positioning of pedicle screws in an equivalently safe manner compared with an open surgical procedure in the acute care of spinal trauma.

Evaluation of Anatomic Relationship between Sural Nerve and Instrumentation during Mini-open Achilles Tendon Repair: A Cadaveric Study

Category:SportsIntroduction/Purpose:The Achilles tendon is one of the most commonly ruptured tendons in the adult population, and there is still no consensus on optimal treatment. While surgical repair may result in a lower re-rupture rate and quicker functional return, it also comes with risk of wound complications and sural nerve injury. If surgical repair is chosen, the surgeon may choose a traditional open procedure, a mini-open technique, or a percutaneous approach. The main advantage of the mini open repair method is the reduced wound complications that comes with a much smaller incision, while still maintaining similar re-rupture rates. The purpose of this study was to determine the relationship of the sural nerve to the Arthrex PARS jig and repair sutures.Methods:Cadaveric dissection was performed on 10 unpaired above knee amputation specimens. After severing the Achilles tendon and inserting the jig for a mini open repair, the sural nerve was dissected out to determine the rate of nerve puncture by the passed sutures. The jig was then removed to determine if the nerve was bound by the passing sutures or wrapped during suture locking.Results:The sural nerve was punctured 9 times out of the total of 50 sutures passed for an 18% puncture rate. All 9 punctures occurred in 4 specimens (Image 1), with the remaining 6 cadavers sustaining no punctures. Of the 6 unpunctured cadavers, 5 had all sutures passing anterior to the sural nerve, but in close proximity. One cadaver had all sutures passing posterior to the sural nerve. In all cadavers, removal of the jig and locking of the sutures left the sural nerve free with the sutures well fixed within the Achilles tendon. The sural nerve was also found to be within 1 cm of the lateral edge of the mini-open transverse incision in all cadavers.Conclusion:The Arthrex PARS jig was successful in preventing binding of the sural nerve during mini-open Achilles repair, but the sutures are often passed directly through the nerve during the procedure. The sural nerve is also at risk at the lateral edge of the mini-open incision used to insert the jig, and must be carefully protected during dissection down to the tendon.

Outcomes of minimally invasive endoscopic pilonidal sinus surgery.

Pilonidal disease is a common condition that is often treated with morbid and painful surgeries. A minimally invasive, endoscopic approach has been described as an alternative to traditional open procedures. It allows the full visualization of the sinus tracks, leaves minimal scarring and results in less pain and a quicker recovery. Patients who underwent minimally invasive endoscopic surgery for pilonidal disease at a major metropolitan hospital in Australia were retrospectively identified. Their operative reports and medical records were assessed to determine analgesic requirements, lengths of hospital stay, recurrence rates of pilonidal disease, and wound complications. Nine patients had endoscopic sinus surgery (six male, three female). All patients received treatment from the same surgeon. No patients required opiate analgesia for pain and only one stayed post-operatively in hospital overnight. There were no recorded wound complications. The median follow-up period was 28 months (range, 8-36 months). Eight patients had satisfactory healing recorded during their post-operative consultations. Three patients suffered recurrent disease. Minimally invasive surgery is safe and well tolerated when employed to treat pilonidal disease. It could be considered as a first-line treatment for the obliteration of symptomatic pilonidal sinuses.

Impact of Laparoscopy on Training: Are Open Appendectomy and Cholecystectomy on the Brink of Extinction?

The operative experience of present-day surgical residency training has evolved as a result of the contributions of laparoscopic surgery. Some traditional open procedures are now more descriptive and less of a familiarity to many general surgery residents (GSRs). The aim of this study was to investigate how open operative experience compares with laparoscopy for GSRs. A retrospective, multicenter, consecutive cohort study of all patients undergoing surgical intervention involving the appendix and gallbladder identified from the ACS-NSQIP database over a 2.5-year period. All GSR postgraduate year-level operative experience was recorded. Of 777 procedures, 13 laparoscopic appendectomy conversions to open (4.3%) by Rocky-Davis (15%) or lower midline (84.6%) incisions were performed versus 285 that remained laparoscopic (95.6%). Fifty (10.4%) open cholecystectomies (38 open + 10 conversions + 2 common bile duct (CBD) exploration), 27 (5.6%) laparoscopic cholecystectomies with cholangiogram, and 402 (83.9%) laparoscopic cholecystectomies were performed. Twenty-nine different GSRs participated in procedures. Eighty-five (10.9%) operations were performed with multi-postgraduate year levels. Surgical residents have an unequal operative experience for case-specific open procedures. A competency-based system to demonstrate a resident's hands-on surgical skills is fundamental to residency training and should be considered for specific types of low-volume open surgical cases.

Proposal for a Revised Classification of the Depth of Neuromuscular Block and Suggestions for Further Development in Neuromuscular Monitoring.

Proposal for a Revised Classification of the Depth of Neuromuscular Block and Suggestions for Further Development in Neuromuscular Monitoring.

Complication avoidance in minimally invasive spinal surgery.

Minimally invasive techniques in spinal surgery allow surgeons to perform operations with less of the approach-related morbidity inherent to traditional open procedures. Yet these muscle-sparing procedures come with a unique set of risks that stem from the novel approaches, limited exposure, and/or a restricted working corridor that they employ. The literature suggests that these operations can be performed without an increased rate of complication once the associated learning curve has been surmounted, suggesting that knowledge of and experience with the nuances of these procedures are essential for patient safety. The present article describes the complications specific to a variety of minimally invasive spinal surgeries and provides guidance on how to avoid them.