Vertical Incision Research Articles

Risk factors for postoperative ileus after cesarean delivery

Despite extensive data regarding risk factors for postoperative ileus in the general and colorectal surgery literature, few studies have identified risk factors specific to the obstetrical population. This study aimed to identify factors associated with postoperative ileus following cesarean delivery. This retrospective case-control study identified women who underwent cesarean delivery at a single hospital between January 2000 and January 2020 and subsequently developed postoperative ileus. Cases were matched in a 1:2 ratio with controls who underwent cesarean delivery and did not develop postoperative ileus. They were matched by age (±1 year) and body mass index (±1 kg/m2). Demographics, common comorbidities, obstetrical history, and delivery characteristics were analyzed. A total of 147 cases and 294 controls were identified. Cases and controls were similar in terms of parity, number of previous cesarean deliveries, labor preceding their cesarean delivery, incidence of chorioamnionitis, and presurgical diagnosis of hypothyroidism or chronic hypertension. Cases tended to have a diagnosis of preeclampsia (cases 23.1% vs controls 10.5%; P<.001) and were more likely to have been exposed to magnesium sulfate (cases 34.0% vs controls 15.0%; P<.001). Surgical considerations that were common in cases were exposure to general anesthesia (cases 37.4% vs controls 4.1%; P<.001), midline vertical skin incisions (cases 13.6% vs controls 1.4%; P<.001), classical hysterotomy (cases 8.8% vs controls 1.7%; P=.001), estimated blood loss >1000 mL (cases 44.4% vs controls 11.6%; P<.001), transfusion of blood products (cases 25.8% vs controls 2.0%; P<.001), and hysterectomy at the time of cesarean delivery (cases 6.1% vs controls 0.7%; P=.001). After a multivariable modeling using stepwise logistic regression of all variables found to be statistically significant, transfusion of blood products, estimated blood loss >1000 mL, and exposure to general anesthesia were the remaining surgical factors associated with the development of ileus. These variables reflect both the complexity and most likely the duration of surgery that was required, although we note that we did not have operative time as a variable to explore. Preeclampsia was also identified as a comorbidity linked to the development of ileus. A diagnosis of preeclampsia, exposure to general anesthesia, estimated blood loss >1 L, and transfusion of blood products were identified as potential risk factors for postcesarean ileus.

TU2.4 Synthesis review with meta-analysis on risk of incisional hernia following transverse versus vertical midline incision for specimen extraction in patients undergoing laparoscopic colorectal resections

Abstract Objective The objective of this article is to explore the risk of incisional hernia (IH) occurrence at the site of specimen extraction following laparoscopic colorectal resection (LCR), highlighting the comparison between transverse incision versus midline vertical abdominal incision. Method Analysis was conducted according to PRISMA guidelines. Systematic search of medical databases like MEBASE, MEDLINE and pubmed was performed to find all types of comparative studies reporting the incidence of IH at the specimen extraction site of transverse or vertical midline incision following LCR. The analysis of the pooled data was done using the RevMan statistical software. Result Twenty-five comparative studies (including 2 RCTs) on 10362 patients fulfilled the inclusion criteria. There were 4944 patIents in the transverse incision group and 5418 patients in the vertical midline incision group. In the random effects model analysis, the use of transverse incision for specimen extraction following LCR reduced the risk of IH development [odds ratio 0.30, 95% CI (0.19–0.49), z= 4.88, p=0.00001]. However, there was significant heterogeneity (Tau2 = 0.97; Chi2= 109.98, df = 24(p=0.00004; I2 = 78%) among included studies. Conclusion Transverse incision used for specimen extraction following LCR seems to reduce the risk of postoperative IH incidence compared to vertical midline abdominal incisions.

Competing Narratives: Examining Obstetricians’ Decision-Making Regarding Indications for Cesarean Sections and Abdominal Incisions

This article examines the decision-making process among obstetric residents in a public maternity hospital in Mexico where the percentage of cesareans and of classical vertical incisions (rather than the more common transverse incision) were both higher than those recommended by the World Health Organization or national standards. Data were collected in 2018 through free list methodology (listing items that fall within a particular cultural domain or category) and semi-structured interviews with senior obstetric residents. Analysis revealed two competing narratives at work that influenced decision-making regarding the use of cesareans and incision type: though participants emphasized the importance of clinical indications, their reported decisions seemed to rely more heavily on subjective and non-clinical factors. Factors such as patient “type” and perceived pressure from patients influenced obstetricians’ decisions to perform cesareans. Decisions about performing incision-type seemed based on a combination of clinical factors, surgical abilities, and structural pressures. The data illustrate the nuanced and contradictory elements within medical decision-making ideas and behaviors.

Narcotic waste in the operating room and immediately post operatively in gynecologic oncology surgery (118)

Narcotic waste in the operating room and immediately post operatively in gynecologic oncology surgery (118)

Preventing caesarean section wound complications: use of a silver-impregnated antimicrobial occlusive dressing.

To investigate the role of an adherent soft silicone antimicrobial occlusive foam silver-impregnated dressing for reduction of surgical site infections (SSI) in primary low-transverse caesarean section (1°LTCS) delivery. Women aged 18-45 years admitted to the labour and delivery or the antepartum unit undergoing a 1°LTCS were recruited. Exclusion criteria included repeat caesarean, vertical skin incision, intrapartum fever and closure with staples. Consented participants delivered by scheduled or unscheduled 1°LTCS received the silver-impregnated dressing. Those who declined to participate and were delivered by scheduled or unscheduled caesarean received a standard gauze with tape dressing (controls). Surgical preparation and preoperative antibiotics were administered as per hospital policy. A total of 362 participants were consented for use of the silver-impregnated dressing, with 190 participants undergoing 1°LTCS, of whom 185 were included in the final analysis. Of those who declined to participate, 190 ultimately underwent 1°LTCS during the same time period. Cases and controls were similar in demographics, body mass index, diabetes status, labour and procedure length, and tobacco use. The overall incidence of SSI was 3.7%. A 50% reduction in incidence of SSI was observed in the silver-impregnated dressing group compared with control group (2.7% versus 4.7%, respectively), but this was not statistically significant (p=0.08; odds ratio 0.55; 95% confidence interval: 0.18-1.67). Among women undergoing 1°LTCS with subcuticular closure of a transverse incision, use of a silver-impregnated dressing reduced the rate of SSI by >50% but was not statistically significant.

Comparative Assessment of Flap-Advancing Techniques in an Ex Vivo Cadaverous Porcine Model.

Since flap advancement is a prerequisite for tension-free primary closure and successful regenerative procedures, the aim of this study was to test the efficacy of six surgical approaches for flap advancement in an ex vivo porcine model. A total of 60 fresh mandibles from pigs were randomized into one of six groups: (1) trapezoidal full-thickness flap design with two vertical releasing incisions (control), (2) trapezoidal flap with linear periosteal scoring, (3) mucosal detachment technique, (4) mucosal detachment with horizontal extension, (5) mucosal detachment with horizontal and vertical extension, and (6) mucosal detachment with horizontal vertical and cutback extension. Coronal advancement of the flap was recorded as the primary variable; the surface area of exposed mucosa and the tear strength were recorded as secondary variables. Homogeneity existed among groups for preoperative keratinized tissue width and tissue thickness. Mucosal detachment with horizontal, vertical, and, cutback extensions achieved the highest amount of advancement. All remaining groups achieved a statistically higher advancement compared with the trapezoidal full-thickness flap (control). Pairwise comparison demonstrated statistical significance between any two groups (P < .001). A positive correlation was noted between exposed mucosa and flap advancement; the advancement increased 0.62 mm for each 10 mm2 of increase in the exposed mucosal surface. Strength at tear stress was the highest in the trapezoidal full-thickness flap (control) and mucosal detachment with horizontal-vertical-cutback incisions (P < .001). Coronal flap advancement was maximized in the mucosal detachment techniques and positively correlated with the area of exposed mucosa.

Penile Fracture with Urethral Rupture

Penile fracture with an associated urethral injury is a rare urological emergency resulting from trauma to the erect penis during vigorous sexual intercourse. The patient often presents with swelling of the penis, discoloration of the penile skin, localized pain, and hematuria with a typical history of sudden detumescence during intercourse. Subcoronal penile degloving incision has been conventionally described and is frequently used by many clinicians for the management of penile fracture-urethral injury. Here, we describe a case of complex penile fracture managed through the vertical penoscrotal incision. The penoscrotal approach confers excellent exposure to both the ruptured corpus cavernosum and urethra. This approach ensures successful outcomes in such an emergency procedure without having disadvantages of the degloving incision.

The shortest distance between the skin and the peritoneal cavity is obtained with fascial elevation: a preliminary prospective laparoscopic entry study.

The purpose of this study was to prospectively compare the measurement of skin-to-fascia distances in the neutral state, during manual elevation and by fascial elevation in patients who underwent laparoscopic surgery. In 53 patients, the distance between the skin and anterior wall of the rectus sheath was measured prospectively in following three different ways: (1) in neutral position, (2) during manual elevation and (3) during elevation of the fascia using forceps following an infraumbilical vertical skin incision. In all patients, subcutaneous tissue up to the fascia was dissected after a vertical skin incision. The skin-to-fascia distance of 30.9 mm (14.0-52.0 mm) in the neutral position decreased to 11.1 mm (0.0-26.0 mm) during the fascial elevation, while the mean distance increased to 40.1 mm (19-70 mm) during manual elevation (p < 0.001). In the closed laparoscopic entry technique in which a Veress needle is inserted into the peritoneum through a small incision, the needle should be introduced from the shortest distance between the skin and the peritoneum. Lifting the fascia with a proper surgical instrument in suitable patients could enable us to achieve this goal.

Complications of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery

ObjectiveCompare complication rates of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery. Study designRetrospective cohort study examining induction for abortion or fetal demise for pregnancies from 14w0d to 23w6d gestation at 2 urban academic medical centers from 2009 to 2019. Exclusion criteria included preterm labor or cervical insufficiency, neonatal interventions, or if misoprostol was not the primary induction method. Complication rates were compared between those with no prior, 1 prior, and 2 or more (2+) prior cesarean deliveries. Complications analyzed were retained placenta, failed induction, infection, hemorrhage, blood transfusion, uterine rupture, intensive care unit admission, death, and readmission. Secondary analysis included cumulative misoprostol dosages and complete abortion rate within 24 hours. ResultsOf 520 patients, 411 patients had no prior cesarean delivery, 77 had 1 prior cesarean delivery, and 32 had 2+ prior cesarean deliveries. Eleven patients had a prior vertical uterine incision. About 26.5% of all patients received mifepristone. The 2+ prior cesarean delivery group was significantly older (35 vs 32 vs 32, p < 0.001) and more likely to be induced for fetal demise (62.5 vs 41.56 vs 39.17%, p = 0.04). Both cesarean groups were more likely to be obese (58.62 vs 49.35 vs 34.26%, p = 0.003). Patients with 2+ prior cesarean deliveries were more likely to experience uterine rupture (6.25 vs 0 vs 0%, p = 0.004), and require ICU admission (6.45 vs 1.3 vs 0.49%, p = 0.02). Secondary analysis outcomes were similar. Logistic regression showed patients with 2+ prior cesarean deliveries were more likely to experience a complication than those with 1 prior (adjusted odds ratio [aOR] 2.71, confidence interval [CI] 1.09–6.86, p = 0.03) or 0 prior cesarean deliveries (aOR 3.00, CI 1.30–7.02, p = 0.01). Patients with 1 prior or no prior cesarean deliveries had a similar risk of experiencing a complication (aOR 1.11, CI 0.64–1.89, p = 0.7). ConclusionsMost patients with prior cesarean deliveries can safely undergo induction in the second trimester for abortion or fetal demise. Patients with 2+ prior cesarean deliveries had a higher rate of at least 1 complication when compared to those with one or no prior cesarean delivery, despite similar misoprostol dosages and rates of complete abortion. ImplicationsThis large 10-year retrospective study examines the impact of prior cesarean delivery on the safety of second trimester induction. While second trimester labor induction abortion remains an option for all patients, specialized counseling for patients with 2 or more prior cesarean deliveries may be warranted.

Surgical Site Infections after Cesarean Delivery: Incidence and Assessment of Associated Risk Factors

Background: Surgical site infection (SSI) after C-section is one of the major concerns of health care providers because it not only increases the overall hospital cost, length of patients’ hospital stay but it largely contributes to the mortality and associated morbidity. In this present study, we aimed to expose the associated risk factors of SSI. Materials and methods: The present study was conducted in the Department of Obstetrics and Gynecology, MMC Kathua, w.e.f September 2019 to August 2020. A total of 394 women patients were included in the study on the basis of laid down inclusion and exclusion criteria. The study was under taken after approval by the institutional Ethical committee. Results: The incidence of surgical site infection was observed as (11.4%) and average age of studied patients was (31.6±9.38) with most of the patients, accounting for 86.5% were falling in the age interval of (25-35) years followed by 10.7% patients ageing less than 25 years We found that surgical site infection was significantly associated with type of surgery, type of incision and type of suturing. Conclusion: The present study revealed that surgical site infection is significantly associated with emergency surgery, vertical skin type incision and interrupted suturing. We recommend regular screening and implementation of health education programs to impart knowledge of associated risk factors of SSI that will eventually help the patients to attain optimal health benefits. Keywords: Caesarean section, surgical site infection, vertical incision, suturing.

Single midline incision approach for decompression of greater, lesser and third occipital nerves in migraine surgery

BackgroundThe traditional approach for occipital migraine surgery encompasses three separate surgical incisions in the posterior neck to decompress the greater occipital nerves (GON), lesser occipital nerves (LON), and third occipital nerves (TON). Other incisions have been investigated, including singular transverse incisions. We sought to evaluate a single, vertical midline incision approach for decompression of all six occipital nerves.MethodsUsing 10 cadaveric hemi-sides (5 fresh cadaver head and necks). Anatomic landmarks and the location of the bilateral GON, LON, and TON were marked according to previous anatomic studies. A single, midline 9-cm incision was made, and lateral skin flaps were raised to decompress or avulse all six nerves.ResultsThrough the midline incision, the GON and TON were identified at 3.5 and 6.2 cm, respectively, inferior to a line bisecting the external auditory canal (EAC) and 1.5 cm lateral to the midline. The LON was identified as 6-cm inferior and 6.5-cm medial to a line bisecting the EAC in the plane just above the investing layer of the deep cervical fascia until the posterior border of the sternocleidomastoid was encountered. The LON had the greatest amount of variation but was identified lateral to the posterior border of the SCM.ConclusionsA single midline incision approach allows for successful identification and decompression of all six occipital nerves in migraine surgery.

Continuous measurements of valley floor width in mountainous landscapes

Abstract. Mountainous landscapes often feature alluviated valleys that control both ecosystem diversity and the distribution of human populations. Alluviated, flat valley floors also play a key role in determining flood hazard in these landscapes. Various mechanisms have been proposed to control the spatial distribution and width of valley floors, including climatic, tectonic, and lithologic drivers. Attributing one of these drivers to observed valley floor widths has been hindered by a lack of reproducible, automated valley extraction methods that allow continuous measurements of valley floor width at regional scales. Here, we present a new method for measuring valley floor width in mountain landscapes from digital elevation models (DEMs). This method first identifies valley floors based on thresholds of slope and elevation compared to the modern channel and uses these valley floors to extract valley centrelines. It then measures valley floor width orthogonal to the centreline at each pixel along the channel. The result is a continuous measurement of valley floor width at every pixel along the valley, allowing us to constrain how valley floor width changes downstream. We demonstrate the ability of our method to accurately extract valley floor widths by comparing with independent Quaternary fluvial deposit maps from sites in the UK and the US. We find that our method extracts similar downstream patterns of valley floor width to the independent datasets in each site, with a mean width difference of 17–69 m. The method works best in confined valley settings and will not work in unconfined valleys where the valley walls are not easily distinguished from the valley floor. We then test current models of lateral erosion by exploring the relationship between valley floor width and drainage area in the Appalachian Plateau, USA, selected because of its tectonic quiescence and relatively homogeneous lithology. We find that an exponent relating width and drainage area (cv=0.3±0.06) is remarkably similar across the region and across spatial scales, suggesting that valley floor width evolution is driven by a combination of both valley wall undercutting and wall erosion in the Appalachian Plateau. Finally, we suggest that, similar to common metrics used to explore vertical incision, our method provides the potential to act as a network-scale metric of lateral fluvial response to external forcing.

Skin Incision Selection in Superobese Women Undergoing Cesarean Birth.

The aim of this study was to examine whether vertical versus transverse skin incision is associated with increased wound complications in superobese women undergoing cesarean. This is a secondary analysis of a retrospective cohort study that included women with a body mass index (BMI) ≥ 50 kg/m2 and a cesarean birth with documented skin incision type from 1/1/2008 to 12/31/2015 at a single academic medical center. The primary outcome was a composite of wound complications: infection requiring antibiotics including superficial cellulitis, deep and organ space infections requiring packing, vacuum placement or exploration and debridement in the operating room. Secondary outcomes included estimated blood loss (EBL), time from skin incision to delivery, need for classical or T-hysterotomy, prolonged hospital admission (>4 days), and a composite of adverse neonatal outcomes. The primary exposure was skin incision type, transverse or vertical. Modified Poisson regression variance was used to adjust for differences in baseline characteristics. During the study period, 298 women underwent a cesarean with a known skin incision type. Vertical skin incision occurred in 25.8%. Women with a vertical skin incision were younger, had a higher BMI at delivery, had less weight gain in pregnancy, and were less likely to have labored prior to cesarean. Wound complications were not significantly more common in women with a vertical skin incision after adjusting for covariates (vertical 48.1 vs. transverse 29.4%, adjusted relative risk (aRR): 1.31, 95% confidence interval [CI]: 0.92-1.86). Compared with a transverse skin incision, vertical skin incision was associated with an increased risk for classical hysterotomy (67 vs. 17%, aRR: 2.96, 95% CI: 2.12-4.14), higher EBL, prolonged hospital stay, and composite neonatal morbidity. There were no statistically significant differences in the time from skin incision to delivery. In superobese women, vertical skin incision was not associated with increased wound complications, but was associated with increased risk for classical hysterotomy. · Vertical skin incision was not associated with a higher risk for composite wound morbidity after adjusting for covariates.. · Vertical skin incision was significantly associated with classical hysterotomy without associated decrease in incision to delivery time or neonatal morbidity.. · When selecting a skin incision approach in superobese women, clinicians should consider whether potential benefits outweigh known risks..

Risk of Uterine Rupture and Dehiscence Among Women Attempting a Vaginal Birth After a Low Vertical Uterine Incision [A232

INTRODUCTION: The risk of uterine rupture after a prior low vertical (LVCS) is unknown. The objective of this study was to estimate the risk of uterine rupture in individuals attempting a trial of labor after cesarean delivery (TOLAC) with a prior LVCS. METHODS: This is a secondary analysis of the Maternal Fetal Medicine Units Network’s C-section Registry, a multicenter, prospective observational study. We included individuals with term singleton pregnancies undergoing TOLAC with a prior low transverse incision (LTCS) or LVCS and excluded those who received prostaglandins or had a history of myomectomy. Multivariate regression models were used to estimate the relative risk between uterine rupture with a prior LVCS compared to LTCS. After controlling for known confounders, our secondary outcome was uterine dehiscence. RESULTS: In this cohort, 14,773 individuals attempted TOLAC (14,665 prior LTCS; 108 prior LVCS). Uterine rupture occurred in 94 (0.7%) of women with prior LTCS and 1 (0.1%) woman with prior LVCS. Uterine dehiscence occurred in 101 (0.7%) of individuals with prior LTCS and 3 (2.9%) of individuals with prior LVCS. Compared to those with a prior LTCS, the risk of uterine rupture was not different (RR, 1.49; 95% CI, 0.21–10.58). However, the risk of uterine dehiscence was increased among those with prior LVCS (RR, 4.07; 95% CI, 1.31–12.63) compared to prior LTCS. CONCLUSION: Individuals with a prior LVCS have an increased risk of uterine dehiscence, but not uterine rupture, compared to prior LTCS. These results may inform counseling for those individuals considering TOLAC after prior LVCS.

V06-12 LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY: AN OPTION IN COMPLEX ADULT PATIENT TO ACCESS TO THE BLADDER

You have accessJournal of UrologyCME1 May 2022V06-12 LAPAROSCOPIC MITROFANOFF APPENDICOVESICOSTOMY: AN OPTION IN COMPLEX ADULT PATIENT TO ACCESS TO THE BLADDER Roberto Hugo Martinez Rodriguez, Cristina Gutierrez Ruiz, Leire Portilla Maediavilla, Fatima Castroviejo, and Jose H. Amon Sesmero Roberto Hugo Martinez RodriguezRoberto Hugo Martinez Rodriguez More articles by this author , Cristina Gutierrez RuizCristina Gutierrez Ruiz More articles by this author , Leire Portilla MaediavillaLeire Portilla Maediavilla More articles by this author , Fatima CastroviejoFatima Castroviejo More articles by this author , and Jose H. Amon SesmeroJose H. Amon Sesmero More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002586.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Mitrofanoff principle was originally described in paediatric population as a method to provide an alternative access to the bladder. It creates a conduit to the bladder through which patients with a sensitive, absent or traumatized urethra can perform clean intermittent catheterization (CIC) easily. We report our experience with complete laparoscopic approach in an adult patient with complex urogenital malformation and multiple previous surgeries. METHODS: 39 years old female patient born with urogenital sinus plus anorectal atresia and bicornuate uterus with several reconstructive surgeries during neonatal and infant period. Previous to the surgery, the patient was performing several CIC per day with increasing difficulty, pain and urethrorrhagia. The patient was incontinent due to elevate post-voiding residue due to an ineffective evacuation by catheter. Low bladder pressure was confirmed by urodynamics. Pelvic MRI showed atypical morphology of the bladder after previous surgery plus cystic image in the right iliac fossa related to anexial cyst without visualizing the anal sphincter complex. RESULTS: A 4 port transperitoneal approach was used :2 of 10 mm laparoscopic ports and 2 of 5 mm ports. The 10 mm camera port was placed trough the umbilicus and the rest in the midline and lateral to the edge of the rectus abdominis muscle. After liberation of several abdominal adherences, we found the appendix and right hemicolon medially and cranially displaced. The appendix was harvested with preservation of the vascular supply and ligated at its base. The appendix was assessed to determine whether the length was adequate to reach the anterior abdominal wall. The bladder was filled with saline and a 3 cm vertical seromuscular incision was made in the right posterior wall of the bladder down to the mucosa. Appendicovesical anastomosis was then performed, and seromuscular layer of the bladder was closed creating a tunnel for the appendix. The tightness of the bladder anastomosis was tested by bladder filling. Care was taken to ensure absence of twisting or tension on the appendiceal mesentery. The appendix was then brought up to the abdominal wall and a catheterizable stoma was created with 8 Fr catheter left through the appendix. The operative time was 300 min and estimated blood loss was 120 cc. The patient was discharged at eighth day. CONCLUSIONS: Pure laparoscopic Mitrofanoff appendicovesicostomy is feasible in adult patients even with previous and complicated surgeries. Pure laparoscopic Mitrofanoff is associated with reasonable outcome, early recovery and good cosmesis. The main disadvantage is the long operative time due to anatomical challenges. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e568 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Roberto Hugo Martinez Rodriguez More articles by this author Cristina Gutierrez Ruiz More articles by this author Leire Portilla Maediavilla More articles by this author Fatima Castroviejo More articles by this author Jose H. Amon Sesmero More articles by this author Expand All Advertisement PDF DownloadLoading ...

AGE‐RELATED CHANGES IN THE STRUCTURE OF THE CAVOTRICUSPID ISTHMUS IN AN EAST AFRICAN POPULATION

The cavotricuspid isthmus (CTI) is a concave, quadrilateral region of the right atrium between the ostium of the inferior vena cava (IVC) and the tricuspid valve (TV). Three levels of the isthmus have been described from supero‐medial to inferolateral aspects as para‐septal, central and inferolateral isthmus. Antero‐posteriorly, the CTI is also described in three sectors; posterior, middle and anterior sectors, with variable morphologies. The CTI is a common site for atrial flutter (AFL) macro‐reentrant circuits and its histological structure, dimensions and proximity to the right coronary artery (RCA) and minor coronary vein (MCV) are the key determinants of both the occurrences as well as success of management of these AFL. Interestingly, both the prevalence as well as post‐ablation complications of AFL are higher in elderly populations, suggesting possible age‐related histological and morphometric changes in the CTI. Despite this possibility, age‐related histomorphological changes of the CTI are yet to be described. Thus, this study’s objective was to determine the age‐related changes in the structure of the CTI by testing the hypothesis that there are age‐related changes in the structure of the CTI.40 morphologically normal hearts with intact CTI were obtained from post‐mortem heart specimens at Chiromo Funeral Parlor and Kenyatta National Hospital Mortuary following ethical approval by the Kenyatta National Hospital ‐ University of Nairobi Ethical Review Commission. Subjects were classified according to 4 age groups; &lt;20, 21‐35, 36‐50, &gt;50. This study used vertical inter‐caval incisions on the posterior aspect of the right atrium. The gross appearance of the CTI sectors was determined as either trabeculated/membranous/recessed. Additionally, light microscopy and histology were used to identify myocardial architecture. Means and standard deviations of linear measurements were calculated and correlated for heart weight. Gross morphology and histo‐architecture were presented in photo‐macrographs and photomicrographs. Results demonstrate that myocardial thickness and proximity of the RCA to the endocardium increased among the 0‐20 to 21‐35 age groups, but reduced in the 36‐50 and &gt;50. The distance of the MCV from the endocardium increased with age but dropped in the &gt;50 age group. Moreover, an increase in age is correlated with an increase in sub‐Eustachian recess prevalence, prevalence of a trabeculated posterior sector, a combination of trabeculae bridges, ridges and intra‐trabeculae recesses within the middle sector. These findings suggest that thinning of the myocardium as well as the increase in heterogeneity of trabeculations, associated with an increase in age, are the structural basis behind the high prevalence of AFL among the elderly. Furthermore, the close proximity of minor coronary veins to the endocardium and the high prevalence of sub‐Eustachian recess may account for the difficulties during ablation and recurrence of AFL post‐ablation associated with advancement in age.

Influence of Prior Vertical Uterine Incision on Subsequent Cesarean Delivery Characteristics and Outcomes [A85

Influence of Prior Vertical Uterine Incision on Subsequent Cesarean Delivery Characteristics and Outcomes [A85

Rotational Occipital Scalp Flap for Occipital Pressure Ulcer.

Occipital pressure ulcers and wound gaping may occur in unconscious and malnourished patients. Most of the time, a large defect requires wound coverage by scalp flaps. This video describes a rotational occipital scalp flap for occipital pressure ulcer and wound gaping in a patient of operated midline posterior fossa mass & ventriculoperitoneal shunt. The defect measured 2.25 × 2.5 cm with exposed inion. The wound was included in an imaginary triangle, and the horizontal and vertical incision lengths were about four times the base of the triangle. The flap was based on the left occipital artery and raised in an avascular plane above the periosteum. The wound margins were freshened and undermined. The flap was rotated to bring it over the defect, and suturing was done in the standard manner. The flap had good healing, and the patient continued to be under care for his cerebellar medulloblastoma.

Aesthetic reconstruction of the scar contracture deformity in chin and neck with expanded flaps based on the "MRIS" principle

Objective: The surgical reconstruction strategy for scar contracture deformity in chin and neck was explored, aiming to obtain better aesthetic outcome. Methods: A retrospective observational study was conducted. From December 2017 to April 2021, 34 patients with scar contracture deformity in chin and neck after burns were hospitalized in the Department of Plastic Surgery of the First Affiliated Hospital of Army Medical University (the Third Military Medical University), aged 12-54 years, including 13 males and 21 females, 4 cases with chin affected only, 7 cases with neck affected only, and 23 cases with both chin and neck affected. The scar areas were 48-252 cm2. All the patients were treated by operation with expanded flaps, following the "MRIS" principle of matching of the color and thickness of the repair flaps (match), reconstructing of the aesthetic features of subunits (reconstruction), design of incision according to the plastic principle (incision), and prevention of the surgical incision scar (scar). The rectangular or kidney shaped skin and soft tissue expander (hereinafter referred to as the expander) with rated capacity of 80-400 mL was embedded in the first stage, which was routinely expanded to 3-5 times of the rated capacity of the expander. In the second stage, scar resection and expanded flap excision were performed to repair the secondary wound, and the flap donor site was sutured directly. The expansion ratio of the expander (with average value being calculated), the type of flaps used, the reconstruction of local aesthetic morphology, the appearance of postoperative incision, the survival of flap, and the situation of donor and recipient sites observed during follow-up were recorded. Results: Among the 34 patients, the average expansion ratio of the implanted expander was 3.82 times of the rated capacity of the expander. Three cases were repaired by the expanded local pedicled flap only, 19 cases by the expanded shoulder and/or chest perforator pedicled flap only, 10 cases by the expanded local pedicled flap combined with the expanded shoulder and/or chest perforator pedicled flap, and 2 cases by the expanded local pedicled flap combined with the expanded free flap of the second intercostal perforator of internal thoracic artery. After scar resection, the shapes of lower lip and chin-lip groove were reconstructed in 10 cases, chin process reconstruction and chin lengthening were performed in 16 cases, and the cervico-mental angle and mandibular margin contour were reconstructed in 28 cases. The surgical incision was concealed, most of which were located at the natural junction or turning point of the chin and neck subunits. The vertical incision of neck was Z-shaped or fishtail-shaped. All the expanded flaps in 34 patients survived after operation, of which 8 patients had minor necrosis at the edge or tip of the expanded flaps 1-3 days after operation and healed after dressing change. During the follow-up of 3-18 months, little difference in color and thickness between the expanded flap and the skin of chin and neck was observed, and the aesthetic shape of chin and neck was significantly improved, with mild scar hyperplasia of surgical incision. Conclusions: Reconstruction of scar contracture deformity in chin and neck by using expanded flaps based on the "MRIS" principle is beneficial to improve the quality of surgery and achieve better aesthetic outcome.

Efficacy of modified thoracoabdominal nerves block through perichondrial approach in open gynecological surgery: a prospective observational pilot study and a cadaveric evaluation

BackgroundModified thoracoabdominal nerves block through perichondrial approach (M-TAPA) was first described as a peripheral nerve block by Tulgar in 2019. This technique provides an analgesic effective range from Th7–11 with a single puncture per side. Although the efficacy and effective duration of M-TAPA have been reported, further examination is required. Therefore, this study aimed to evaluate the analgesic range and effective duration of M-TAPA in open gynecologic surgery.MethodsFollowing approval, 10 adult female patients scheduled for open radical hysterectomy via a vertical incision or laparotomy using a midline incision from under the xiphoid process to the symphysis pubis were enrolled. The primary outcome was the number of anesthetized dermatomes at 2 and 24 h postoperatively. Secondary outcomes included numerical rating scale scores and the total amount of fentanyl used. Cadaveric evaluation was performed to assess the spread of the dye.ResultsThe median numbers (interquartile range) of anesthetized dermatomes at 2 and 24 h postoperatively were 6 (5–7) and 6.5 (5–7) in the anterior cutaneous branch area and 5 (4–7) and 7 (5–7) in the lateral cutaneous branch area, respectively. There was an 85% chance of simultaneously acquiring analgesia in areas innervated by Th8–11, including complete block in areas innervated by the anterior cutaneous branches of Th9–10. Cadaveric evaluation showed the spread of the dye in Th8–11.ConclusionsM-TAPA may have analgesic effects in the areas supplied by the anterior cutaneous branches of Th8–11.Trail registrationIRB approval (No.2700; registered on July 10, 2020) and registration (UMIN Clinical Trials Registry: UMIN000041137; registered on July 17, 2020).