Wide Dissection Research Articles

Customization in minimally invasive orthognathic surgery

Patient-specific implants are currently a new reality to orthographic surgery. Among other advantages offered by this technology, the following stand out: Splintless surgery; Maxillary three-dimensional repositioning with no vertical reference needed and minimal mandible proximal segment rotation. Most of the available patient-specific systems requires extended incisions to accommodate the cutting and drilling guides and the patient-specific fixation plates, with wide dissection. “Minimally invasive surgery” is already a well-known concept in several medical specialties, which has also recently been adopted in orthognathic surgery with its potential benefits. The authors of this article describe the customization of fixation devices under the concept of minimally invasive approaches.

RECURRENT MALIGNANT APOCRINE SWEAT GLAND CARCINOMA - A CASE REPORT

Apocrine carcinomas arise from normal or modified sweat glands. The slow-growing nature and rarity of sweat gland carcinomas complicate their diagnosis at the early stage. The incidence of PASGC is quite low at 0.0049–0.0173 cases/100,000 persons/year. A 21-year-old male patient was presented in February 2016 with small solitary mass in the right axilla with mild tenderness and pain. Underwent wide local excision and axillary dissection at our institution followed by adjuvant radio and chemotherapy. Later on, after 18 months developed local recurrence and was planned for re-surgery and a second phase of palliative radiotherapy. After a year, presented to the hospital with pin sized irregular swelling in the axilla. Sweat gland carcinomas which are rarely diagnosed create a pathological dilemma due to their unpredicted biological behavior. However, wide local excision with or without nodal dissection is the primary treatment till date. In this particular case even though patient had underwent axillary node dissection, patient had recurrence twice with no distant metastasis which is a key point to be noted. Thorough study of the available apocrine carcinoma case reports or case series, the better knowledge regarding the apocrine carcinoma can be obtained.

Evaluation of Double Mesh Modification of Chevrel’s Technique in Management of Midline Incisional Hernia

Background: Chevrel’s technique provides tensionfree repair of midline incisional hernia, but wide skin and subcutaneous dissection increases rate of complications. Here, we evaluate the double mesh modification of Chevrel’s technique in midline incisional hernia repair.
 Methods: 22 patients with midline incisional hernia underwent double mesh modification of Chevrel’s technique. After excision of hernial sac with minimal dissection of the skin and subcutaneous tissue, the anterior rectus sheath is incised on both sides to create medial flaps that are sutured toeach other. Both recti abdominis muscles were dissected off the posterior rectus sheath, opening the retrorectus space. Prolene mesh was fixed in the retrorectus space with prolene sutures, and tailored to cover the bare area of anterior surface of both recti muscles and fixed to the lateral flaps of the anterior rectus sheath with interrupted prolene sutures.
 Results: We observed no recurrences, no skin necrosis, two cases of seroma, one case of superficial wound infection and one case of temporarychronic pain.
 Conclusion: Double mesh modification of Chevrel technique is an efficient method for treatment of midline incisional hernia, with minimal surgical site occurrences.
 Keywords: Chevrel technique, Double mesh technique, Midline incisional hernia

Best Practices in Robotic-assisted Repair of Vesicovaginal Fistula: A Consensus Report from the European Association of Urology Robotic Urology Section Scientific Working Group for Reconstructive Urology

ContextSurgical repair of a vesicovaginal fistula (VVF) has been described extensively in the literature for several decades. Advances in robotic repair have been adopted since 2005. ObjectiveA consensus review of existing data based on published case series, expert opinion, and a survey monkey. Evidence acquisitionThis document summarizes the consensus group meeting and survey monkey results convened by the European Association of Urology Robotic Urology Section (ERUS) relating to the robotic management of VVF. Evidence synthesisCurrent data underline the successful robotic repair of supratrigonal nonobstetric VVF. The panel recommends preoperative marking of the fistula by a guidewire or ureteral catheter, and placement of a protective ureteral JJ stent. An extravesical robotic approach usually provides a good anatomic view for adequate and wide dissection of the vesicovaginal space, as well as bladder and vaginal mobilization. Careful sharp dissection of fistula edges should be performed. Tension-free closure of the bladder is of utmost importance. Tissue interposition seems to be beneficial. The success rate of published series often reaches near 100%. An indwelling bladder catheter should be placed for about 10 d postoperatively. ConclusionsWhen considering robotic repair for VVF, it is essential to establish the size, number, location, and etiology of the VVF. Robotic assistance facilitates dissection of the vesicovaginal space, harvesting of a well-vascularized tissue flap, and a tension-free closure of the bladder with low morbidity for the patient being operated in the deep pelvis with delicate anatomical structures. Patient summaryRobotic repair of a vesicovaginal fistula can be applied safely with an excellent success rate and very low morbidity. This confirms the use of robotic surgery for vesicovaginal fistula repair, which is recommended in a consensus by the European Association of Urology Robotic Section Scientific Working Group for reconstructive urology.

The impact of locoregional treatment on response to nivolumab in advanced platinum refractory head and neck cancer: The need trial.

e18508 Background: Immunotherapy is the standard of care in the treatment of platinum-refractory recurrent/metastatic head and neck squamous cell carcinoma (R/M-HNSCC). Previous loco-regional treatment could have an impact on the immune system and response to Nivolumab. The aim of this study is to evaluate the efficacy and safety of Nivolumab in a real world population, identifying the impact of the clinic-pathological characteristics and previous treatment in prediction of early progression. Methods: This is a observational, multicenter retrospective/prospective study including patients (pts) with platinum refractory R/M HNSCC who received Nivolumab 240 mg every 2 weeks until disease progression or unacceptable toxicity, from October 2018 to October 2019. We analyzed treatment outcomes in term of early progression (within 3 months), clinical benefit, progression free survival (PFS) and overall survival (OS). To determine the influence on outcomes, the following variables were investigated: primary tumor sub-site, age, gender, ECOG, previous loco-regional treatment, previous systemic therapy, metastatic site. Results: Data from 61 pts were reviewed: 15 oral cavity, 14 oropharynx, 7 hyphofarynx, 19 larynx, 6 paranasal sinus. Median age was 66 years (29-82), 48 pts were men. Forty-nine pts (80%) had performance status (ECOG) ≥ 1 at baseline evaluation. Eleven pts (18%) had only loco-regional recurrence, while 50 pts (82%) had one or more metastatic site. 32 (52%) and 17 pts (28%) had smoking and alcohol abuse history, respectively. 44 pts (72%) received surgery followed by adjuvant radiant treatment at standard dose (28, 46%) or concomitant definitive radiotherapy (16, 26%) as upfront treatment with curative intent. With a median follow up of 4 months (range 1-11), early progression occurred in 39 pts during Nivolumab treatment (64%), while clinical benefit (stable disease and partial response) was achieved in 22 pts (36%). No G3-G4 toxicities occurred. Early progression to Nivolumab was significantly associated to previous loco-regional treatment both at univariate and multivariate analysis (p=0.003 and p= 0.04, respectively). Conclusions: Nivolumab in R/M HNSCC is effective and safe even though burdened with a high early progression rate. Loco-regional treatment, including wide neck dissection and high dose radiotherapy, may compromise the efficacy of Nivolumab, distorting the anatomy of the local lymphatic system and hindering the priming of immune response.

PD46-11 TECHNIQUES THAT REDUCE PARS FIXA AND PARS PENDULANS URETHRAL ANASTOMOTIC COMPLICATIONS DURING RADIAL FOREARM FREE FLAP PHALLOPLASTY

INTRODUCTION AND OBJECTIVE: Transmasculine individuals interested in radial forearm free flap (RFFF) phalloplasty with full length urethroplasty are counseled on high urethral complication rates. The most common site for a postoperative urethral complication is the pars fixa (PF) and pars pendulans (PP) urethral anastomosis, which reportedly occurs in 40% to 50% of patients. Distal pars fixa urethral complications are rare; therefore, maximization of blood flow to the proximal PP urethral component of the RFFF may decrease urethral fistula and stricture formation. We describe our experience with flap harvest techniques that preserve blood flow to this region of the RFFF. METHODS: PF urethral reconstruction utilized labia minora flaps without use of any vaginal wall flaps. PP urethral reconstruction involved the volar portion of the RFFF with a 1-2cm proximal extension for the urethral component of the flap. Blood flow to and from this portion of the RFFF was maximized using the following techniques: 1) preservation of direct arterial perforators, when present; 2) keeping a dermal skin bridge to the proximal PP urethra; 3) wide dissection of an adipofascial layer; 4) preservation of a “urethral” vein. The added benefit of the adipofascial layer around the proximal PP urethra is tissue coverage over the PF-PP anastomosis. We retrospectively reviewed the outcomes of RFFF phalloplasty patients who underwent urethral reconstruction. RESULTS: From Oct 2017 to Oct 2019, 79 patients underwent RFFF phalloplasty with full-length urethroplasty. Mean followup is 12 months (range 0-23 months). Urethrocutaneous fistulas and/or urethral strictures developed at the PF-PP anastomosis in 27 (34%) patients: 7 patients had a PF-PP urethral stricture and fistula, 5 had an isolated anastomotic stricture, and 15 patients had a fistula with 11 patients spontaneously healing the fistula by 6 weeks. The total urethral revision rate for patients with a non-healing fistula and/or stricture at the PF-PP urethral anastomosis was 14% (11 patients). There are two patients with mild strictures and three with a fistula who are still being monitored and have not yet had urethral reconstruction. CONCLUSIONS: Techniques directed towards preservation of blood flow to the proximal urethral component of a RFFF phallourethroplasty reduces risk of urethral complications. More than half of the fistulas healed spontaneously, and most strictures required urethroplasty. Source of Funding: none

Safety of early discharge with a chest tube after pulmonary segmentectomy.

Early removal of chest tube is an important step in enhanced recovery after surgery protocols. However, after pulmonary resection with a wide dissection plane, such as pulmonary segmentectomy, prolonged air leak, a large volume of pleural drainage and the risk of developing empyema in patients can delay chest tube removal and result in a low rate of completion of the enhanced recovery after surgery protocol. In this study, we aimed to assess the safety of discharging patients with a chest tube after pulmonary segmentectomy. We retrospectively reviewed a single surgeon's experience of pulmonary segmentectomy from May 2019 to September 2019. Patients who fulfilled the criteria for discharging with a chest tube were discharged and provided written instructions. They returned for chest tube removal after satisfactory resolution of air leak or fluid drainage. In total, 126 patients underwent pulmonary segmentectomy. Ninety-five (75%) patients were discharged with a chest tube postoperatively. The mean time to chest tube removal after discharge was 5.6 (range 2-32) days, potentially saving 532 inpatient hospital days. Overall, 90 (95%) patients experienced uneventful and successful outpatient chest tube management. No life-threatening complications were observed. No patient experienced complications resulting from chest tube malfunction. Five (5%) patients experienced minor complications. Overall, all patients reported good-to-excellent mobility with a chest tube. Successful postoperative outpatient chest tube management after pulmonary segmentectomy can be accomplished in selected patients without a major increase in morbidity or mortality.

DIRECT RESULTS OF SURGICAL TREATMENT OF THREE-NEGATIVE BREAST CANCER

Three−negative breast cancer is characterized by aggressive clinical course, early metastasis and poor prognosis, leading to more active oncosurgical tactics and systemic treatment. Due to the aggressive clinical course of this oncopathology with increasing risk of locoregional and distant metastases, the most common surgical treatment tactics are modified variants of radical mastectomy with wide dissection of lymph nodes in areas of potential metastasis. Radicalism of the operation is the cause of the increase in the incidence of wound and lymphoenosis, the development of which depends on many factors, the determination of which is important for the development of methods of prevention of complications. In recent years, in the early stages of the disease, a radical breast resection after a course of adjuvant radiotherapy has been considered as an alternative. To study the immediate post−surgery results of three−negative breast cancer, depending on the initial clinical and pathological parameters and features of therapeutic tactics, a study was conducted in which 66 patients participated. Patients underwent radical mastectomy and breast resection, as well as lymph node dissection. Nine patients underwent aloplastic reconstruction. The results of the analysis showed that most often after radical surgeries, irrespective of their volume, there are lymphovenous complications, the development of which is affected by an increase in body mass index and lesions of lymph nodes. Aloplastic breast reconstruction contributes to a reduced incidence of lymphoid complications, and neoadjuvant chemotherapy is associated with an increased incidence of wound complications. These factors should be considered when planning the surgery protocols of patients with three negative breast cancer. Key words: three−negative breast cancer, surgical treatment, postoperative complications, risk factors.

Reverse Sural Flap for Repair of Foot and Ankle Defects: Our Cases, Modifications, and a Literature Review

Introduction: Reverse-flow sural flap is a valuable option in cases of lower extremity repair. In this study, we aimed to present our sural flap applications and modifications for the treatment of ankle and foot defects and to evaluate our results in the light of historical process and current literature. Materials and Methods: A reverse-flow fasciocutaneous flap was performed in 14 patients to repair foot and ankle defects. In 6 cases (42.86%), we chose to perform interpolation sural flaps where we aimed to repair the distal defects of the foot and/or in order to prevent patients from having trouble wearing shoes due to bulkiness of the flap pedicle at the ankle. In other cases (tunnel flap group, 57.14%), the pedicle of the flap was passed through the subcutaneous tunnel. Wide and meticulous dissection of the tunnel, nitroglycerine application on the flap, and close flap monitoring were our protective measures. Our results were analyzed statistically. The literature review was performed from Medline and PubMed. Results: Sural flap repair was performed in 14 patients. The mean age was 32.75 years. Etiologic factors were traffic accidents, spinal cord injuries, and hyperkeratotic lesions. The defects were localized in the ankle or proximal foot in 12 (85.71%) patients and the distal foot in the remaining patients (14.29%). The mean area of the defects was 46.75 cm2. Partial necrosis at the distal flap developed in 2 (25%) cases in the tunnel group and in 1 (16.67%) in the interpolation group (3 cases in total, 21.43% in the study population). No statistical difference was found between the flap groups in terms of patient distribution and complications. Conclusion: Wide dissection of the subcutaneous tunnel through which the pedicle is passed (in the tunnel group), application of nitroglycerin, meticulous hemostasis, and postoperative follow-ups are important factors for a successful reverse sural flap application. Sural interpolation modification is advantageous in several cases as the flap can reach farther and does not cause bulkiness in the ankle that would impair shoe wear. However, the disadvantage is that it requires 2 sessions.

Инвертированная папиллома клиновидной пазухи

Inverted papilloma of the nasal cavity and paranasal sinuses is a benign tumor, accounting for approximately 0.4 to 7% of all sinonasal neoplasms. An isolated lesion of one paranasal sinus is a rare disease, it occurs in 5% of cases. Female patient T., 57 years old, with the complaints of violation of nasal breathing on the right, constant nasal congestion of the right half of the nose, periodic congestion of the right ear and headache on the affected side, she was admitted for planned surgical treatment to ENT deprtment of Clinical Medical Center of A. I. Yevdokimov Moscow State University of Medicine and Dentistry for scheduled surgical treatment. The listed symptoms have been observed for about 10 years. Computed tomography showed a subtotal opacification of the right sphenoid sinus with spreading into the nasal cavity and nasopharynx. Preliminarily performed tumor biopsy with the following histological examination established an inverted papilloma. A transnasal endoscopic approach to the posterior sections of the nasal cavity was performed with the removal of the entire front and part of the lower walls of the right sphenoid sinus, removal of the tumor and wide dissection of the mucosa of the posterior sections of the nasal cavity and right sphenoid sinus in order to remove all possible loci of the primary focus. Planning of transnasal surgery begins with establishment a clinical diagnosis, confirmed in doubtful cases by the results of histological examination, analysis of the results of the necessary imaging method, and the selection of an adequate approach that contributes to complete dissection of the pathological formation and safe controlled surgery in aspects of blood loss and the injury of critical neurovascular structures within the least possible time period.

Results of One-Stage Urethroplasty for Hypospadias in Pediatrics – Single Surgeon’s Experience

Introduction: Hypospadias repair is a challenging technique in pediatric urology with a long learning curve. This study presents the results of urethroplasty performed by a single surgeon to repair hypospadias in children and compares the surgical outcomes at different periods. Materials and Methods: From January 2009 to February 2016, patients who were less than 18 years old and were operated for hypospadias were retrospectively reviewed and divided into two groups: group I (from January 2009 to February 2012) and group II (from March 2012 to February 2016). All operations were performed by the same pediatric surgeon, andsurgical outcomes of the two periods were compared. Results: This study considered150 patients (69 in group I/81 in group II). The Mean operative age was 30.4±32.7 months in group I and 33.6±43.3 months in group II(p=0.309). The selected procedures mainly depended on the subjective anatomical analysis in the operating room and the surgeon’s preference. The mean follow-up duration was 21.7±28.31 months in group I and 13.6±16.6 months in group II (p=0.033).The overall complication rate was 44.9% in group Iand 35.8% in group II (p=0.316). The incidence of glanular disruption significantly decreased from 21.7% to 6.2% (p=0.007) because of the wide dissection of the glanular wings and the deep incision of the urethral plate, which led to tension-free sutures for glanular reconstruction. Conclusions: One-stage repair of hypospadias may achieve satisfactory outcomes in cosmetic appearance and voiding function. Surgical outcomes could be improved by increasing practice.

Laparoscopic preperitoneal ventral hernia repair with prolene mesh with fixation through transabdominal prolene stitches

Objective To evaluate the efficacy and safety of our technique in laparoscopic repair of ventral hernias. Summary background data Laparoscopic ventral hernia repair (LVHR) was first reported in 1993. The successful application of laparoscopic techniques for the repair of ventral hernias has been well accepted. The recurrence rate after standard repair of ventral hernias may be as high as 10%, and the wide surgical dissection required often results in wound complications. Use of a laparoscopic approach may decrease rates of complications and recurrence after ventral hernia repair. Patients and methods Data on all patients who underwent LVHR performed using our procedure between February 2013 and February 2015 were collected retrospectively. Results LVHR was completed in 27 of the 30 patients (nine men and 21 women) in whom it was attempted. The patients’ mean BMI was 36.5; the mean defect size was 3.2 cm. Mesh averaging 6.3 cm was used in all cases. Mean operating time was 105 min, and hospital stay averaged 1.9 days. Our complication rates were 16.6%. The most common complications were ileus (6.6%) and prolonged seroma (6.6%). During a mean follow-up time of 12 months, the hernia recurrence rate was 3.3%. Overall, 10% of patients had pain for 1 month. Recurrence was associated with vigorous exercise within the first 3 months postoperatively. Conclusion In this series, the preperitoneal laparoscopic technique for ventral hernia repair had a low rate of conversion to open surgery, a short hospital stay, a moderate complication rate, and a low risk of recurrence avoiding the potential complications related to intraabdominal mesh position.

Transsylvian, Carotid-Oculomotor Triangle Approach for Resection of a Rapidly Enlarging Midbrain-Pontine Cavernous Malformation: 3-Dimensional Operative Video.

Cavernous malformations (CM) of the anterior midbrain are best reached through an orbitozygomatic (OZ) approach with removal of the orbital rim and wide Sylvian fissure dissection. Our surgical video demonstrates this approach to resect a ruptured CM in a 36-yr-old woman who presented with headaches, left face and left arm paresthesias/weakness, and right-sided partial oculomotor nerve (CN III) palsy. Initial magnetic resonance imaging (MRI) showed a midbrain CM, and the patient was managed conservatively. However, 1 wk later, she presented again with worsened left arm and leg weakness and complete CN III palsy. Seven Tesla MRI demonstrated a larger hematoma, and the CM with new mass effect and upper pons extension. The patient underwent a right modified OZ craniotomy and Sylvian fissure split under guidance of intraoperative neuronavigation and with neuromonitoring. The carotid-oculomotor triangle and the Liliequist membrane were dissected to access the midbrain, and CN III was identified and followed posteriorly to the midbrain. Confirmed with neuronavigation, a longitudinal incision of the midbrain was performed, and the CM was encountered. The hematoma and CM were debulked and removed in a piece-meal fashion, leaving hemosiderin-stained brain intact to prevent unnecessary additional damage to the midbrain. Postoperative MRI confirmed gross-total resection, and the patient's weakness recovered substantially. In this video, we demonstrate that the brainstem is no longer forbidden surgical territory, and show how the use of neuronavigation for surgical planning, positioning, and approach, in addition to the understanding of safe entry zones and meticulous microsurgical technique have made safe and effective surgery on the brainstem possible.

Sacrospinofixation of Richter in 8 Points: Original Contribution of the Laparoscopic Column in the Visualization of the Sacrospinous Ligaments

Although the standard technique is currently based on laparoscopic promontofixation, the standard vaginal technique for the treatment of uterine prolapse is sacrospinofixation according to Richter [1-3]. Described by Kurt Richter in 1968, this intervention corrects the middle floor and consists of fixing the vaginal dome (after hysterectomy or not) on the sacrospinous ligament(s) [4,5]. The technique includes a wide dissection of the pararectal fossa using several Breisky valves to grip the sacrospinous ligament under strict visual control. This crucial step of the intervention implies optimal visual control for the operator but does not allow visual access to the operative assistants, which is regrettable for the purpose of teaching [2,4-6]. The aim of this surgical video is to describe the different stages of the sacrospinofixation surgical technique, showing sacrospinous ligaments during the crucial step thanks to a laparoscopic camera. A step-by-step explanation of the surgery using a video (an instructive video [Video 1]) approved by the local ethics committee. Gynecological Surgery Unit, University Hospital of Strasbourg, Strasbourg, France. A 70-year-old woman with multicompartment pelvic organ prolapse. Installation in the conventional gynecologic position with 2 operating assistants on both sides of the operator. The steps are as follows: step 1, posterior colpotomy; step 2, rectovaginal dissection and opening of the pararectal fossa; step 3, dissection of the sacrospinous ligament; and step 4, gripping of the sacrospinous ligament. The following 4 steps are realized bilaterally: step 5, suspension of the vaginal dome; step 6, beginning of vaginal closure; step 7, tightening the spinofixation threads; and step 8, ending the closure of the vaginal colpotomy. The operative time was 60 minutes. The operation was simple and shows precisely the sacrospinous ligaments. There were no intraoperative complications. The vaginal mesh urinary catheter was removed on day 1, and the patient was discharged on day 3. Thanks to a laparoscopic column, this video of the surgical technique of sacrospinofixation using the Richter procedure is an original approach to show sacrospinous ligaments. The latter is a crucial step of this surgery, which remains the reference vaginal technique for the treatment of a uterine prolapse.

Response to Letter: Upper eyelid platinum weight placement for the treatment of paralytic lagophthalmos: A new plane between the inner septum and the levator aponeurosis.

In your study, it is stated that “the levator aponeurosis was dissected free from the anterior tarsal surface.” We think that this statement is ambiguous, and interpreted it as indicating that sufficient dissection was performed to fix the gold weight to the levator aponeurosis. It seems that this would require wide dissection, which may lead to unintentional damage to the levator aponeurosis or adjacent tissue. Moreover, the space between the preaponeurotic space and the levator aponeurosis would be very narrow for suture fixation of the uppermost central portion of the levator aponeurosis to the gold weight, and as a result, this could be a traumatic procedure.

Wide Dissection and Intercostal Vessel Division Allows for Repair of Hypoplastic Aortic Arch Through Thoracotomy.

The approach to coarctation of the aorta with hypoplastic aortic arch is controversial. We evaluated the outcomes in patients with coarctation of the aorta with or without hypoplastic aortic arch operated through a posterior left lateral thoracotomy. A retrospective cohort of patients with aortic coarctation, who underwent repair between January 2009 and October 2017, was analyzed. Preoperative, postoperative, and echocardiographic characteristics were reviewed. Statistical analysis examined survival, freedom from reintervention, and freedom from recoarctation. In nine years, 389 patients who underwent surgical treatment for coarctation of the aorta were identified; after exclusion criteria and complete echocardiographic reports, 143 patients were analyzed, of which 29 patients had hypoplastic aortic arch. The modification in the extended end-to-end anastomosis technique was a wide dissection and mobilization of the descending aorta that was achieved due to the ligation and division of 3 to 5 intercostal vessels. In both groups, patients were close to one month of age and had a median weight of 3.6 and 3.4 kg for hypoplastic and nonhypoplastic arch, respectively. In postoperative events, there was no statistically significant difference between the groups ( P = .57 for renal failure, P = .057 for transient, nonpermanent neurologic events, P = .496 for sepsis), as for intensive care unit ( P = .502) and total in-hospital stay ( P = .929). There was one case of postoperative mortality in each group and both were associated with noncardiac comorbidities. Regarding survival (log-rank = 0.060), freedom from reintervention (log-rank = 0.073), and freedom from recoarctation (log-rank = 0.568), there was no statistically significant difference between the groups. We believe that it is the modified technique that allowed greater mobilization of the aorta and successful repair of hypoplastic arch through thoracotomy, without an increase in paraplegia or other adverse outcomes.

Redefining the Anatomic Boundaries for Safe Dissection of the Skin Paddle in Free Gracilis Myofasciocutaneous Flaps—An Indocyanine Green Cadaveric Study

There is no financial information to disclose. Anatomical studies of the gracilis myocutaneous flap describe the skin paddle to be limited to the proximal two-thirds overlying the gracilis muscle. This study describes the area of skin that can be safely harvested with a free extended gracilis muscle flap on a single vascular dominant pedicle with wide fascia harvest. The skin paddle is designed overlying the length of the gracilis muscle and dissection is carried down to the deep fascia. The deep fascia is then harvested wider than the margins of the skin paddle circumferentially, from the anteromedial fascia of the thigh to the posterior edge of the gracilis with its investing fascial sleeve. The gracilis and overlying skin are kept in continuity to preserve distal skin paddle perfusion. The deep fascia and skin paddle are sutured together to prevent shearing injury of the fasciocutaneous perforating branches. Using a cadaveric model, 9 free flaps were evaluated using indocyanine green (ICG) with cadaveric blood as the carrier. The ICG was injected into the single vascular dominant pedicle, the deep branch of the medial circumflex artery. These extended gracilis free flaps were compared with the standard gracilis free flap (investing fascia only) with the same sized skin paddle via the same injection technique. Imaging was performed using the SPY Elite and SPY-PHI (Stryker). In a cadaveric model, the extended gracilis free flap exhibited ICG perfusion to a 40 x 21-cm skin paddle, whereas the standard gracilis skin paddle demonstrated ICG perfusion to an area of 22 x 11 cm (Figure 71-1). The extended gracilis free flap demonstrated perfusion of 587 cm2 more surface area, equating to over 330% greater skin surface coverage than the standard gracilis myocutaneous free flap. •Wide dissection of the deep fascia beyond the margins of the skin paddle can improve viability of the distal skin overlying the gracilis myocutaneous flap (Figure 71-2).•The extended myofasciocutaneous gracilis free flap is useful in patients for whom free functional muscle transfer and additional skin coverage are required.•Wide fascial dissection of the extended gracilis free flap can increase viable skin overlying the gracilis myocutaneous flap by over 330% of the standard surface area.•ICG can be a valuable tool to evaluate perforasomes in cadaveric studies.Figure 71-2Myofasciocutaneous gracilis free flap zone of skin perfusion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Component separation hernioplasty in treatment of postoperative ventral hernias

The presence of large defects in the anterior abdominal wall in patients is an important problem for surgeons, due to the complexity of the hernioplasty implementation, the need to use large mesh, high frequency of postoperative complications. Nowadays, widely used laparoscopic hernioplasty include the use of mesh materials. In patients with large hernias, laparoscopic techniques are associated with a number of technical difficulties during operations and a high frequency of postoperative relapses (up to 30 %). The problem of choosing the treatment method for postoperative ventral hernias of large and gigantic still remains unsolved. Currently, the main trend is to restore the anterior abdominal wall anatomical integrity with the reduction of the anterior abdominal wall muscles to the white abdominal line and open component separation. Since the development of laparoscopic and endoscopic technologies, the technique of endoscopic separation of the anterior abdominal muscles has been improved to improve the quality of life of patients and to reduce the incidence of postoperative complications and recurrences. The use of endoscopic methods makes it possible to prevent a wide tissue dissection, reduce the risk of necrosis of the skin and aponeurotic flap through the preservation of perforant vessels in the anterior abdominal wall. The result comparison between the use of open and laparoscopic methods of component separation showed that the use of open separation methods leads to a significantly greater number of both intraoperative and postoperative complications associated with the development of 30 % of necrosis of the skin and aponeurotic flap, and relapses. The results of the studies indicate some advantages in reducing the frequency of postoperative wound complications with endoscopic component separation methods in patients with postoperative large size ventral hernias.

Features of anterior and lateral vertebral body surface dissection on thoracic and lumbar levels from anterolateral and lateral approach

Objective. To study anatomical features of anterior and lateral vertebral body surface dissection in thoracic and lumbar region from anterolateral and lateral approaches.Materials and methods. Twenty surgeries were performed on 5 unembalmed cadavers. Procedures were provided in autopsy room. On every cadaver full lateral and anterior vertebral body dissection from right thoracotomy on middle-thoracic (Th4-Th8) level, left thoracotomy on low-thoracic (Th9-Th12) level, left extracaelomic retropleural-retrophrenic-retroperitoneal, thoracotomy with horizontal dissection of diaphragm and wide classical thoraco-abdominal with hemisection of diaphragm in thoraco-lumbar junction (Th12-L1), right and left lateral lumbotomy in middle lumbar levels (L2-L4), middle retroperitoneal in low lumbar levels (L4-L5).Results. Parietal pleura incision allow on thoracic level ease subpleural dissection anterior and lateral surface of vertebral body, without risk of visceral and vascular complication. For direct anterior vertebral wall visualization ventral widening of approach must be done. Dissection of mid-lumbar vertebral body surface can be done as from classical left, as right sided lateral approach without vascular problem, if 3 level segmental arteries and veins ligation was done, according to technique we use. Common iliac vessels transposition can be done after meticulous ligation all venous afferents at L5 level.Conclusions. Limited small transthoracic (rib resection 5-10 cm), extracaelomic approach in all cases far enough for full lateral wall vertebral body dissection. But no vascular control and anterior vertebral body wall visualization can be accomplished. To obtain direct control for wide dissection of vertebral body with full aorta delineation direction of surgical manipulation should be changed from posterolateral to anterolateral (rib resection 15-20 cm, hemisection of diaphragm). Ligation of all lateral afferent at L5 level of common left iliac vein allow uncomplicated dissection of L5 vetebral body wall in experiment.

Variations of Occipital Artery-Posterior Inferior Cerebellar Artery Bypass: Anatomic Consideration.

Advances in diagnosis of posterior inferior cerebellar artery (PICA) aneurysms have revealed the high frequency of distal and/or dissecting PICA aneurysms. Surgical treatment of such aneurysms often requires revascularization of the PICA including but not limited to its caudal loop. To examine the microsurgical anatomy involved in occipital artery (OA)-PICA anastomosis at various anatomic segments of the PICA. Twenty-eight PICAs in 15 cadaveric heads were examined with the operating microscope to take morphometric measurements and explore the specific anatomy of bypass procedures. OA bypass to the p2, p3, p4, or p5 segment was feasible with a recipient vessel of sufficient diameter. The loop wandering near the jugular foramen in the p2 segment provided sufficient length without requiring cauterization of any perforating arteries to the brainstem. Wide dissection of the cerebellomedullary fissure provided sufficient exposure for the examination of some p3 segments and all p4 segments hidden by the tonsil. OA-p5 bypass was placed at the main trunk before the bifurcation in 5 hemispheres and at the larger hemispheric trunk in others. Understanding the possible variations of OA-PICA bypass may enable revascularization of the appropriate portion of the PICA when the parent artery must be occluded. A detailed anatomic understanding of each segment clarifies important technical nuances for the bypass on each segment. Dissection of the cerebellomedullary fissure helps to achieve sufficient exposure for the bypass procedures on most of the segments.