Wide Sutures Research Articles

Pycnodysostosis: Report of A Rare Case

A 20-year old male patient reported in the outpatient department of Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh, with the complaints of body aches along with pain in the upper and lower limbs for several years. He also gave history of previous hospitalization for the same reason. He also had complaints of failure to thrive in his adolescence. However, he was treated as a case of polyarthritis in his previous admission in the district hospital. On clinical examination, he was found to have short stature, low-weight, peculiar face, prominent forehead, receding jaw and partial dysplasia of the terminal phalanges. He was sent for radiological investigations in the Department of Radiology & Imaging of the same hospital. Plain radiograph of his skull showed brachycephaly with wide sutures and persistent fontanelles with sclerotic changes in the base of skull and orbital rims. The angle of the mandible was obtuse, and the maxilla was found hypoplastic. Lumbar region showed ‘spool-shaped’ vertebral bodies with quite prominent anterior defects; bones had sclerotic changes. Both hands had acro-osteolysis of distal phalanges of thumb, index, middle and ring fingers (both right and left sides) along with irregular distal fragments; bones were sclerotic, too. Those features were consistent with pycnodysostosis. The patient was kept admitted into the hospital and treated accordingly. After obtaining a written informed consent, he was presented as a special case in clinical seminar.
 Mugda Med Coll J. 2022; 5(2): 110-113

A Floppy Infant with Facial Dysmorphism.

A Floppy Infant with Facial Dysmorphism.

Fossil infructescence from southwestern China reveals Paleogene establishment of Cladrastis in Asia

While a recent molecular phylogeographical study shows that, Cladrastis, a small woody genus in the bean family (Leguminosae), may have been established in Asia after the middle to late Eocene, fossils of the genus have not been previously documented in the Paleogene of Asia. Here we report an infructescence and four fossil fruits of Cladrastis from the Paleogene of southeastern Yunnan, China, which we described as a new species, C. haominiae, and this represents the first Paleogene record of Cladrastis in Asia. These fossils are characterized by a long stipe, an acuminate or acute proximal/distal end, wide sutures, and elliptical seed(s) nearly parallel or forming a small angle to the long axis of the fruit. Our finding supports the Paleogene establishment of Cladrastis in Asia and provides new significant evidence for the Paleogene origin of Yunnan biodiversity.

The Wide Suture Suspension Platysmaplasty, a revised technique for neck rejuvenation: A retrospective cohort study.

Restoration of an esthetic neck contour is an integral component of facial rejuvenation. The corset platysmaplasty and the suture suspension neck lift were introduced by Feldman in 1990 and by Giampapa in 1995, respectively. Both techniques are routinely used in current practice with satisfactory and long-lasting results. However, some patients who have undergone the suture suspension platysmaplasty report long-term discomfort, excessive neck tightening, and recurrence of deformity. To achieve an improvement in the Cervicomental (CM) angle and other parameters in patients with a difficult neck and to reduce the probability of long-term discomfort, excessive neck tightening, and a recurrence of deformity. The author developed a new technique that includes a very wide suture suspension with no interlocking. We hereby present a revised suture suspension technique-The Wide Suture Suspension Platysmaplasty. Between the years 2015 and 2017, the senior author performed 286 face and neck rejuvenation surgeries with or without blepharoplasty. Of these cases, 35 patients with a heavy neck were chosen for the new Wide Suture Suspension Technique. This was a single surgeon retrospective cohort study. Patients were photographed in a lateral view preoperatively and 6months postoperatively. Pre- and postoperative photographs were compared in four measured parameters: the cervicomental angle, the jowl angle, the horizontal distance between the mentum and the cervicomental angle and the vertical distance between the mentum and the cervicomental angle. The Wide Suture Suspension Platysmaplasty resulted in pleasing esthetics, with minimal complications in patients with difficult necks. The cervicomental angle decreased by 42° (P<.0001), the jowl angle increased by 12° (P<.0001), the horizontal distance between the mentum and the cervicomental angle rose by 12.4% and the vertical distance between the mentum and the cervicomental angle was reduced by 34.5%. The Wide Suture Suspension Platysmaplasty resulted in improved esthetics, as demonstrated by objective measurements. None of the patients in this series had any secondary intervention during the follow-up period. Particularly in the case of a difficult neck, surgeons should consider this technique.

Biomechanical comparison of knotless wide suture double-row SutureBridge rotator cuff repair to double-row standard suture repair

A comparison of self-reinforcement and footprint compression between standard- and wide-diameter suture material in double-row SutureBridge repair techniques has not been performed. The aim of this study was to compare the self-reinforcement and footprint contact pressure generated under progressive tensile loads between 2 double-row SutureBridge rotator cuff repair techniques: 1 performed with FiberWire and 1 performed with FiberTape in a knotless technique. Rotator cuff repairs were performed in 10 pairs of ovine shoulders. One group underwent a double-row SutureBridge repair using FiberWire. The other group underwent an identical repair with FiberTape. Footprint contact pressure was measured from 0° to 60° of abduction under loads of 0-60 N. Pull-to-failure tests were then performed. In both repair constructs at 0° of abduction, each 10-N increase in rotator cuff tensile load led to a significant increase in footprint contact pressure (P < .05). The rate of increase in footprint contact pressure was greater in the FiberTape construct (ratio, 1.68; P = .00035). In both repair constructs, the highest values for footprint contact pressure were seen at 0° of abduction. No difference in pull to failure, peak load, or total energy was found between the groups. Self-reinforcement was seen in both double-row SutureBridge repairs with standard- and wide-diameter suture material but was greater in the repair with the wide-diameter suture material construct. Footprint compression is greater in a knotless double-row SutureBridge repair with wide-diameter suture material than in a knotted double-row SutureBridge repair with standard-diameter suture material at 20° of abduction.

Giant Congenital Intracranial Immature Teratoma: A Case Report and Review of Literature

AbstractCongenital intracranial tumour constitute only 0.5–1.5% and are usually associated with poor prognosis. New advancement in imaging may help in early diagnosis. We presented a case of giant fetal intracranial tumour diagnosed antenatally at 28 weeks of gestation in sonography. The magnetic resonance imaging confirmed a large hetrogenous intracranial mass with bilateral ventriculomegaly. Because of the large size of the tumor and associated macrocephaly, the baby was delivered by caessaran section. On delivery, fetal head size was 44.5 cm with wide suture and left facial nerve was involved. Ventriculoeritoneal shunt was inserted on 4th postnatal day, however complete surgical resection of tumour was not performed because of parents refusal. Neonate had rapid increase in head size and expired on postnatal day 16th. The histopathological findings of mass demonstrated a congenital immature teratoma. Neonate expired on 16th postnatal day. Antenatal diagnosis of intracranial tumour is possible with advanced imaging modalities, however an early diagnosis before second trimester is difficult. Prognosis is generally poor and depends on size of tumour, histology and timely intervention.

Creating a Small Anchor to Eliminate Large Knots in Mesh and Tape Suture

Wide mesh or tape sutures are used to close high-tension wounds such as in hernia or tendon repair. However, wide sutures produce large knots that are susceptible to increased palpability, infection, and foreign body response. To prevent such adverse events, we developed a small suture anchor to replace wide suture knots. The suture anchor was iteratively developed using three-dimensional (3D) design software and produced via 3D printing. Anchor prototypes underwent monotonic, cyclic fatigue, and stress-life testing in a benchtop soft tissue suture model. Results were compared to a standard of care knot and alternative suture fixation devices. The final anchor design was selected based on minimal size and mechanical performance. The size of the final anchor (200 mm3) was 33% smaller than a tape suture knot and 68% smaller than a mesh suture knot. Monotonic testing of mesh and tape sutures revealed a significantly greater anchor failure load compared to knot and alternative fixations (p &lt; 0.05). Additionally, all anchors successfully completed cyclic fatigue testing without failure while other fixations, including knot, failed to complete cyclic fatigue testing multiple times. Stress-life testing demonstrated durable anchor fixation under varying tensile stresses. Failure mode analysis revealed anchor fracture and tissue failure as modes of anchor failure, each of which occurred at supraphysiologic forces. We created a small suture anchor that significantly outperforms knot and alternative suture fixations in benchtop testing and addresses concerns of increased palpability, infection, and foreign body response from large suture knots.

Biomechanical Strength of Rotator Cuff Repairs: A Systematic Review and Meta-regression Analysis of Cadaveric Studies

Background: Biomechanical cadaveric studies of rotator cuff repair (RCR) have shown that transosseous equivalent and double-row anchored repairs are stronger than other repair constructs. Purpose: To identify technical and procedural parameters that most reliably predict biomechanical performance of RCR constructs. Study Design: Systematic review. Methods: The authors systematically searched the EMBASE and PubMed databases for biomechanical studies that measured RCR performance in cadaveric specimens. The authors performed a meta-regression on the pooled data set with study outcomes (gap formation, failure mode, and ultimate failure load) as dependent variables and procedural parameters (eg, construct type, number of suture limbs) as covariates. Stratification by covariates was performed. An alpha level of .05 was used. Results: Data from 40 eligible studies were included. Higher number of suture limbs correlated with higher ultimate failure load (β = 38 N per limb; 95% CI, 28 to 49 N) and less gap formation (β = −0.6 mm per limb; 95% CI, −1 to −0.2 mm). Other positive predictors of ultimate failure load were number of sutures, number of mattress stitches, and use of wide suture versus standard suture. When controlling for number of suture limbs, we found no significant differences among single-row anchored, double-row anchored, transosseous equivalent, and transosseous repairs. Higher number of suture limbs and transosseous equivalent repair both increased the probability of catastrophic construct failure. Conclusion: This study suggests that the number of sutures, suture limbs, and mattress stitches in a RCR construct are stronger predictors of overall strength than is construct type. There is a need to balance increased construct strength with higher risk of type 2 failure.

Uterine Compression Suture; New Technique Using Parenchymal Set Suture

Over 125,000 women die of postpartum hemorrhage each year. Important cause is uterine atony and traditional management of this condition includes the use of oxytoxics before proceeding to ligation of internal iliac & uterine arteries and even hysterectomy. Since B-Lynch suture introduced in 1997, there had been many reported new techniques and modification of uterine compression sutures. We reported a case of primigravida in term pregnancy, presented with antepartum haemorrhage due to abruptio placenta complicated with fetal distress. Emergency caesarean section was done and complicated with uterine atony, not responsive to pharmacological therapy. We performed uterine compression suture using technique almost similar as B-Lnch, with modification in suture type used. We used a special parenchymal set manufactured by B-Braun (Figure 1), usually used for adaptation and haemostasis of parenchymal organs such as liver, kidney and spleen. Advantages include wide tape-like suture with its outstanding flexibility and softness lead to excellent tissue approximation, easier knotting and prevention of trauma to uterus by sharp edge of normal suture. The long blunt needle allows for safe handling and suture placement.

Expansion of polyalanine tracts in the QA domain may play a critical role in the clavicular development of cleidocranial dysplasia.

Cleidocranial dysplasia (CCD) is an autosomal-dominant inheritable disease which is secondary to haploinsufficiency of the transcription factor runt-related transcription factor 2 (RUNX2). During the past 10 years, additional cases of RUNX2 mutation have been identified in nearly 500 families with CCD, including familial and sporadic cases (Otto et al. 2002). Some degree of clavicular hypoplasia is the most consistent feature of the disease and is often opposed at the mid line (Tang et al. 2007), while complete absence is rare and complicated to explain the specific mechanism. RUNX2, which is mapped to chromosome 6p21, was identified as the CCD causative gene in 1997 (Mundlos et al. 1997). This gene is the key transcription factor for osteoblastic differentiation, chondrocyte maturation and skeletal morphogenesis (Komori et al. 1997). Moreover, stability of RUNX2 protein, regulated by CBFb, is required for skeletal development by regulating chondrocyte differentiation, proliferation and osteoblast differentiation (Qin et al. 2014). RUNX2-deficient mice displayed impaired bone development manifestation as wide sutures, decreased bone ossification and hypoplastic clavicles (Kundu et al. 2002). RUNX2 consists of eight coding exons and spans a genomic region of 130 kb. According to the analysis of the protein structure, RUNX2 has several functional domains: QA domain, runt domain, nuclear localization signal (NSL), PST domain, VWRPY and nuclear matrix targeting sequence (NMTS). The QA domain, a stretch of 23 polyglutamine and 17 polyalanine tracts, is located in the N-terminus of RUNX2. An in vitro mutagenesis study showed that the QA domain prevented CBFb from binding to RUNX2. Deletionof the QA domain resulted in a four-fold decrease

Triple square extended osteotomies for treatment of scaphocephaly (Renier's "H" technique modification).

Scaphocephaly is the most common single suture craniosynostosis. Surgical technique has evolved from simple strip craniectomy over π-procedures and vertex craniectomies to extensive cranial remodeling which is preferred procedure nowadays. The purpose of this paper is to present our modification of Renier's standard "H" technique and its preliminary results in detail. Eleven patients with scaphocephaly were surgically treated from January 2011 until January 2014. Only children with isolated sagittal synostosis were included in the study. Our modified Renier's technique reduces the possibility of lesion of superior sagittal sinus, dividing parietal bone in three bone fragments, thus achieving shortening of the scull in AP diameter without detaching the bone from the superior sagittal sinus. The possibility for potential secondary stenosis is minimized using extended V-shaped osteotomies with rounding of the bone edges, as well as making wide neocoronal and neolambdoid sutures. Cosmetic results were estimated as very pleasing immediately after surgery by both the parents and the surgeons in all cases. The majority of patients presented in our study were categorized as Sloan Class 1. Improvement or normalization of the cranial index was accomplished in all patients. No revision surgeries were required during the follow-up. Triple square extended osteotomies technique is a fast, simple, and efficient surgical option for children with sagittal synostosis and can be safely applied in the first months of life in children even under weight of 6kilos. Preliminary results are encouraging and deserve a longer follow-up and comparative surgical analysis to verify its usefulness in the future.

Increased perinatal intracranial pressure and brainstem dysfunction predict early puberty in boys with myelomeningocele

Children with myelomeningocele (MMC) run an increased risk of developing early or precocious puberty (E/PP). To identify risk factors for E/PP in boys with MMC. Boys born between 1970 and 1992, treated for MMC at the University Children's Hospital, Uppsala, were identified. Thirty-eight boys were eligible to be included. Medical records were examined retrospectively. Early puberty was defined as pubertal signs before the age of 10 years and 2 months. Precocious puberty was defined as the appearance of these signs before 9 years of age. Increased intracranial pressure perinatally was defined as wide sutures, bulging fontanelles and increased/increasing head circumference at birth and/or during the first week after birth. Early brainstem dysfunction was defined as severe and persistent feeding and respiratory problems before the age of 3 months despite proper control of the hydrocephalus. Of the 38 boys, 8 (21%) had E/PP, which was strongly associated with increased intracranial pressure perinatally and also with early brainstem dysfunction. Multivariate regression analysis showed early brainstem dysfunction to have the highest explanatory value regarding the occurrence of early puberty. Increased intracranial pressure perinatally and brainstem dysfunction early in life are strong predictors of E/PP in boys with MMC.

Craniomicromelic syndrome: First report in a male

We report on craniomicromelic syndrome in a male fetus. This case had the previously reported features of prenatal onset growth retardation, underossified cranial bones, wide sutures and fontanels, small face as compared to head, small palpebral fissures, pinched nose, microstomia, micrognathia, and narrow thorax. The consistent combination of these features with short appearing limbs as observed in this case establishes this syndrome as a distinct entity.

Rotating Distraction Osteogenesis in 23 Cases of Craniosynostosis: Comparison with the Classical Method of Craniotomy and Remodeling

Background: The currently employed technique of distraction osteogenesis (DO) for the surgical treatment of craniosynostosis (CS) is commonly performed due to advantages such as shorter operation time, less bleeding and thus less need for transfusions and a lower risk of infections. Several surgical techniques for the various types of CS have been reported, but a uniform surgical method is as yet unavailable. Methods: We compared 23 patients who underwent rotating DO (RDO) with 15 patients who received conventional craniotomy and remodeling (CR). RDO consisted of suturectomy of the pathologic suture and resection of the bone flap to allow wide suture separation for distraction and open-door rotation. Results: The mean operation duration in the RDO group was 255.9 ± 97.8 min, which was significantly shorter than the 414.0 ± 106.9 min for the CR group (p = 0.0001). Perioperative complications in the RDO group consisted of 2 cases of distractor breakage and 2 cases of minimal pus discharge, while in the CR patients there was 1 case of postoperative epidural hematoma and 1 case of spontaneous bone fracture. Conclusion: We suggest that RDO may be a valid and efficient method for treating children with CS by DO by expanding the intracranial volume and correcting abnormal skull contour shapes.

Incunabula and perizonium of Neidium (Bacillariophyta).

The incunabula and perizonium of a paedogamous Neidium deme (in the N. ampliatum species complex) are described in detail using light and scanning electron microscopy. The incunabula contain two types of element, both heavily silicified. At each pole of the ellipsoidal zygote there is a large cap, which almost abuts its twin on either side of the zygote, beneath the gametangial valves. The caps are deeply and widely notched on their 'girdle' sides (i.e. on the sides of the zygote that underlie the gametangial girdle) and the space created by the notches is filled by large, almost triangular incunabular plates. Thus, on each side of the equator of the zygote there is one cap element and two plate elements. The caps overlap the plates and must precede them ontogenetically, creating a polarity opposite to that of the transverse perizonium. Both elements are sparsely and irregularly porous and have fimbriate margins. During auxospore expansion, the two sets of incunabular elements separate at the equator of the cell and the transverse perizonium is formed beneath, the incunabula continuing to form a tight seal around the perizonium and apparently constraining development to form a linear tube. All transverse perizonial bands possess delicate fimbriae and are open, even the primary band, which is slightly wider than the bands on either side and bears a median ridge. The open ends of the secondary bands sweep strongly towards the centre of the auxospore, producing a very obvious and wide suture. In expanded auxospores, a robust longitudinal band is found beneath the suture, which has coarser fimbriae than the transverse bands. Possible interpretations of the incunabular elements are discussed: no structures similar to the incunabular plates have been described in other diatoms, but it is known that related genera (Biremis, Muelleria) also have large cap-like elements in their incunabula. The open nature of the primary transverse perizonial band is unusual in raphid diatoms, but auxospore coverings have been investigated ultrastructurally in too few diatoms to permit detection of evolutionary trends.

Craniofacioskeletal syndrome: An X‐linked dominant disorder with early lethality in males

A syndrome with multisystem manifestations has been observed in three generations of a Caucasian family. The findings in seven females provide a composite clinical picture of microcephaly, short stature, small retroverted ears, full tip of the nose overhanging the columella, short philtrum, thin upper lip, soft tissue excrescences at the angle of the mouth, small mandible, small hands and feet with brachydactyly, finger V clinodactyly, flat feet, an excessive number of fingerprint arches, and mild impairment of cognitive function. Two males were more severely affected and died in the initial months of life. They showed intrauterine growth retardation, broad cranium with wide sutures and fontanelles, cardiac defects, small hands and feet with abnormal digital creases and small nails, and genital abnormalities. The affected males had low serum calcium in the neonatal period. Serum calcium, phosphorous, and parathormone levels in the females were normal. Radiographs showed cortical thickening of the long bones, underdevelopment of the frontal sinuses, narrow pelvis and hypoplasia of the middle phalanx of finger five. MRI of the brain showed slightly reduced brain volumes and an extra gyrus of the superior temporal region. X-inactivation studies showed near complete skewing in two affected females, but were not informative in three others. X-linkage as the mode of inheritance is proposed on the basis of different severity in males/females, complete skewing of X-inactivation in informative females, and a lod score (1.5) suggestive of linkage to markers in Xq26-q27.

Features of faults in the central and northern Tibetan plateau based on results of INDEPTH (III)-MT

The features of the faults in the central and north- ern Tibetan plateau are discussed, based on two super-wide band magnetotelluric (MT) sounding profiles belonging to the INDEPTH (III)-MT project, which were finished between 1998 and 1999: one is from Deqing to Longweicuo (named line 500), the other is from Naqu to Golmud (line 600). This work assists research on the collision and subduction mode between the India and Asia plates. The MT results show that there is a series of deep faults, F1 to F10, in the central and northern Tibetan plateau. Of these faults, F2 is an earlier main fault which leans to the north, and F1 is a later main overrid- ing fault. The Jiali deep fault zone, which has a very complex space structure, is composed of these two faults. F3, F4 and F5 are super-deep faults. They are high-angle faults and lean a little to the south. The main fault zone of the Bangong- Nujiang suture is composed of these three faults. Because of later activity in the structure, several shallow faults formed in the upper crust within the Bangong-Nujiang suture. The Tanggula fault zone is composed of two main faults, F6 and F7, and a series of sub-faults. The shallow segments of the main faults are in high angles and the deep segments of main faults are in low angles. These two faults generally lean to the south and extend into the lower crust. The Jinshajiang suture is composed of the Jinshajiang fault (F8) and the Kekexili fault (F9), and there is a series of sub-faults in the upper crust between these two faults. The Jinshajiang suture is a very wide suture caused by continent-continent collision. The Middle Kunlun fault (F10), which is the main structure of the Kunlun fault zone, is a high angle, super-deep fault. It is the north boundary of the Songpan-Ganzi-Kekexili block. Based on the conductive structure of the profile, the southern part of the Middle Kunlun fault belongs to the Tibetan plateau, but it is not certain whether the northern part of the Middle Kunlun fault belongs to the Tibetan plateau. There are conductive bodies stretching from the crust into the upper mantle below the Bangong-Nujiang suture and Jinshajiang suture. This may suggest heat exchange between the crust and mantle.

Paleozoic accretionary and collisional tectonics of the eastern Tianshan (China): Implications for the continental growth of central Asia

This paper deals with the various tectonic units in the Chinese Eastern Tianshan orogenic collage in the Central Asian Orogenic Belt, and discusses the Paleozoic geological history of the several periods of accretion and collision of archipelago systems lying between the Tarim and southern Angaran continental margins. The Late Ordovician-Silurian to Early Devonian Eastern Tianshan archipelago was characterized by (a) the Harlik-Dananhu subduction system with a S-dipping polarity in the north; (b) a southerly N-dipping subduction system beneath the Central Tianshan arc in the middle; and (c) the South Tianshan ocean against Tarim in the south. During the Devonian to Early Carboniferous, N-dipping subduction led to the Harlik-Dananhu arc and the Kanggurtag forearc basin/accretionary complex. In the Early to Mid-Carboniferous, the magmatic front associated with the N-dipping subduction beneath the Dananhu-Harlik arc migrated southwards, forming the Yamansu arc constructed upon the Kanggurtag accretionary forearc. By the Late Carboniferous the Dananhu-Harlik arc was attached northwards to the Angaran margin, resulting in lateral enlargement of the Angaran continent. In the latest Carboniferous to Early Permian a multiple soft collision left wide suture zones in the south that include the ophiolite-strewn Aqikkuduk-Shaquanzi and Kumishi accretion-collision complexes, which were stitched by Early Permian post-collisional plutons. By re-defining and re-interpreting the various tectonic terranes, this paper presents a new, improved model for the Paleozoic evolution of this part of Central Asia.

The Anterolateral Transpetrosal Approach to the Clivus and the Pons

Resection of skull base tumors is a real challenge in the field of neurosurgery. Anterior petrosectomy gives one of the best approaches to reach the clivus and the pons while avoiding cerebral retractions which are responsable for postoperative complications. Using a subtemporal extradural or an infratemporal preauricular route, the anterolateral transpetrosal approaches produce a resection of the anterior pyramidal bone around the petrous carotid artery. These approaches offer a direct view of the posterior fossa dura between the two petrosal sinuses, to give access to the petroclival area. However, exposure of the intradural structures in the foramen magnum area is always restricted because of the inferior petrosal sinus. Its peroperative hemostasis is always truly challenging on account of its size and encasement within a wide petrooccipital suture. The goal of the preoperative embolisation of the inferior petrosal sinus, whenever possible, is to allow its peroperative section without haemorrhage for a wider exposure along the lower clivus.

Gasless Laparoscopic Treatment of Perforated Duodenal Ulcer: A Case Report

Ruptured duodenal peptic ulcer is a serious complication of ulcer disease that occurs in approximately 5% of cases. Its emergency treatment is based on surgery, namely, simple closure or more definitive ulcer surgery. Laparoscopic repair of perforated duodenal ulcer with classic insufflation of CO2 is quick, simple, and technically feasible in most patients. We describe herein the operative treatment of a perforated duodenal ulcer in a 33-year-old man who presented to our Hospital with acute onset of severe abdominal pain. Wide peritoneal lavage and suture of the perforation was performed by gasless laparoscopic technique using a mechanical retractor obviating the creation of the pneumoperitoneum and of the sealed environment. This new approach enables the use of conventional instruments and provides a clear field of vision in the abdomen equal to that created by the traditional CO2 technique. Because there is not a pneumoperitoneum to maintain, the gasless technique permits a constant irrigation and suction of the abdominal cavity, a wide peritoneal lavage, and the continuous suction of fluid, blood, smoke, and humidity without losing the camera set. If indicated, it permits the laparoscopic repair of the perforation combined with the laparoscopic vagotomy in the same emergency setting. The present case proved it to be another abdominal procedure that can be carried out with all the technical and anesthesiological advantages of gasless minimally invasive surgery.