Surgeries, Volume 5, Issue 2 (June 2024) – 14 articles

Chylothorax is a rare condition where the extravasated chyle accumulates into the pleural space. It is most commonly associated with malignancies, infective or inflammatory disorders and iatrogenic causes. Extremely rarely, it could occur spontaneously. We present the case of a healthy 40-year-old woman who presented with acute right shoulder and neck pain associated with shortness of breath and loss of consciousness. This was preceded by a yoga class two weeks prior. Chest imaging showed right pleural effusion, and tapping revealed a milky fluid which was confirmed to be chylothorax. Conservative management failed and the patient was successfully treated with video-assisted thoracoscopic drainage, thoracic duct ligation and mechanical pleurodesis. Chylothorax association with yoga is not reported in the literature. Full article

This comprehensive review assessed the integration of robotics and artificial intelligence (AI) in dentistry, offering a transparent overview of developments across dental fields. Covering articles in prosthodontics, orthodontics, implantology, surgery, and radiology, the review included 39 articles on robotics and 16 on AI. Screening adhered to PRISMA guidelines, with searches conducted on Medline, Google Scholar, and IEEE. Incorporating the search strategy, the review used keywords related to dentistry, robotics, and AI. For robotics, 296 articles were screened, resulting in 39 qualifying for qualitative synthesis. A separate AI search on PubMed identified 142 studies within the last decade, with 16 studies selected for a detailed full-text analysis, offering a consolidated overview of the current state-of-the-art knowledge in the AI domain. Geographic distribution highlighted East Asia as a major research contributor. The findings indicate an increasing trend in dentistry robotics since 2000 and, particularly since 2016, in AI dentistry. The majority of the literature fell under the category of basic research. The technology readiness level did not cross “three” (proof of concept) in 41% of all articles. Therefore, the overall literature quality remains low, particularly regarding clinical validation. Full article

The aim of this study was to assess surgical treatment in metacarpal shaft fractures of the second to fifth ray to determine the functional outcomes and complications in open reduction and internal fixation (ORIF) versus closed reduction and internal fixation (CRIF). This was a retrospective study that included patients with metacarpal shaft fractures of the second to fifth rays who were treated surgically between 1 January 2007 and 31 December 2019. Functional outcomes were scored using the QuickDASH and Eq5D score. A total of 231 treated patients were included. Single fractures were seen in 180 patients, and multiple fractures in 51 patients. ORIF was applied in 141 patients and CRIF in 90 patients. The functional outcomes were not significantly different between the groups. Complications were found in 41 (29%) of the ORIF patients and 15 (17%) of the CRIF patients. The functional outcomes after single or multiple metacarpal shaft fractures were similar in the ORIF and CRIF patients. ORIF showed significantly more complications, such as functional impairment and infections and a higher reoperation rate. In conclusion, CRIF is as safe as ORIF for the surgical treatment of metacarpal shaft fractures in terms of its functional outcome and slightly preferable due to its lower complication rate. Full article

Opportunistic salpingectomy (OS) for the primary prevention of ovarian cancer is performed by gynecologists. Advocates have suggested expanding its use to other surgical specialties. General surgeons are the other group to routinely perform intraperitoneal operations in women and could play a role in ovarian cancer prevention. Herein, we review the current evidence and perioperative factors requiring consideration prior to OS implementation in select general surgery cases. A systematic search was conducted for English-language studies evaluating OS during general surgery. The primary outcomes of this study were the feasibility and safety of OS during general surgery procedures. Secondary outcomes included pre-operative considerations (patient selection and the consent process), operative factors (technique and surgical specialty involvement), and post-operative factors (follow-up and management of operative complications). We evaluated 3977 studies, with 9 meeting the eligibility criteria. Few studies exist but preliminary evidence suggests relative safety, with no complication attributable to OS among 140 patients. Feasibility was reported in one study, which showed the capacity to perform OS in 98 out of 105 cholecystectomies (93.3%), while another study reported quick visualization of the fallopian tubes in >80% of cases. All patients in the included studies were undergoing elective procedures, including cholecystectomy, interval appendectomy, colorectal resection, bariatric surgery, and laparoscopic hernia repair. Studies only included patients ≥ 45 years old, and the mean age ranged from 49 to 67.5 years. Gynecologists were frequently involved during the consent and surgical procedures. OS represents a potential intervention to reduce the risk of ovarian cancer. Ongoing studies evaluating the general surgeon’s understanding; the consent process; the feasibility, operative outcomes, and risks of OS; and surgeon training are required prior to consideration. Full article

While anterior cruciate ligament reconstruction (ACL-R) has been considered the gold standard for ACL tears, renewed interest in ACL repair has emerged. This review aims to examine the current knowledge regarding ACL repair. A comprehensive literature search was conducted on the PubMed, Web of Science, Scopus, and Embase databases, focusing on the most recent studies up to January 2024. Arthroscopic ACL repair has several advantages, such as resulting in a natural ligament with proprioceptive properties, preservation, and donor graft comorbidity absence. Several ACL repair surgical procedures have been developed thanks to the advancement in new fixation devices. The current literature showed that when performed on a suitable patient with the appropriate lesion type, corresponding to the proximal third with good tissue quality, ACL repair leads to satisfactory outcomes. Despite the benefits of ACL repair with promising results, ACL-R remains the gold standard for ACL lesions. There is still a lack of literature analyzing long-term outcomes; large series with homogenous populations and types of lesions are lacking. Based on the current evidence, further research and higher-quality studies investigating ACL repair will be necessary. Full article

Patients with end-stage osteoarthritis are recommended to engage in physical activity (PA) to reduce pain and improve function but may avoid PA due to joint pain. Our goal was to investigate patient-reported outcomes and objective mobility metrics (step counts) in total hip arthroplasty (THA) patients as a function of pre-operative PA levels. In total, 1647 patients enrolled in a multicenter prospective cohort study investigating a smartphone-based care management platform for self-directed rehabilitation that underwent THA and were included in analysis. The entire cohort’s step count was divided into quartiles to categorize patients with low, moderate, and high baseline PA. Outcomes including pain, EQ-5D-5L, HOOS JR, and step counts were compared according to activity group by ANOVA. Pre-operative pain scores were lowest, with smallest improvements, in the high-baseline PA group. Low-PA patients demonstrated the greatest improvements in EQ-5D-5L, while changes in EQ-VAS, HOOS JR, and satisfaction were similar between groups. Low- and moderate-PA patients increased physical activity by six weeks, reaching 180% and 114% of pre-operative steps; high-PA patients did not return to full step counts until one-year post-operation. Patients who perform high levels of PA undergoing THA report lower levels of pain and higher function pre-operatively but may appreciate less improvement in PA up to one year post-operatively. These results may be helpful in appropriate counseling of patient expectations prior to surgery. Full article

Autologous fat grafting, or lipotransfer, is an important surgical approach to relocate adipose tissue within an individual to create volume. While used extensively in plastic and reconstructive surgery, significant drawbacks exist, including unpredictable volume retention. Thus, considerable research has been undertaken to identify surgical or therapeutic approaches that improve outcomes, primarily utilizing a xenograft immunocompromised mouse model. Large animal models are an important step in translating preclinical laboratory studies to the clinic, and previous studies utilizing pigs have been applied successfully for fat grafting research, but protocol variability exists across studies, and no previous publication has adequately described the impact of the swine breed on the experimental outcomes. In this report, we provide information on the critical attributes of the swine fat grafting model, including the following: (1) model selection; (2) donor site and surgical harvest approach; (3) tissue processing; (4) recipient site location and preparation; (5) post-operative care; and (6) longitudinal fat grafting assessments. Our experience comparing the use of Yorkshire and Yucatan breeds in our model showed that Yorkshire adipose tissue was fibrotic, extremely difficult to obtain through liposuction, and labor intensive to process into injectable formats. Alternatively, Yucatan adipose was more similar to human tissue, could be readily obtained through the surgical excision of inguinal fat pads, was amenable to mincing with surgical scissors, and yielded injectable tissue with a 95% efficiency. We determined that generation of a surgical pocket reduced the graft migration and spread, consequently facilitating the graft retrieval without significantly impacting retention. Using 5 cc grafts, the ultimate 3-month volume retention in 16 grafts was 19% ± 17% (or 1.14 cc ± 1.08 cc). While the use of ultrasound did not readily enable graft volume approximation during the study, it was a useful method to visualize the graft placement and ensure injection into the subcutaneous adipose layers. Full article

Females of reproductive age constitute one of the largest demographics of the hip arthroscopy population, but it is unclear as to how pregnancy planning affects decision-making regarding surgery or vice versa. The purpose of this study was to assess perceived risks to pregnancy from hip pain and/or hip arthroscopy among reproductive-age females who underwent arthroscopic treatment of femoroacetabular impingement syndrome (FAIS). A cross-sectional study was conducted involving females aged 18–44 years who underwent hip arthroscopy for the treatment of FAIS, with a single surgeon included in the study. Subjects completed a survey that assessed obstetric and gynecologic history, decision-making regarding the planning and timing of hip surgery and pregnancy, and perceived risks to pregnancy from hip pain and/or hip surgery. Subjects were classified as nulligravid (Group 1), pregnant at least once before hip surgery but never again following hip surgery (Group 2), or pregnant at least once following hip surgery (Group 3). A total of 85 patients were enrolled with a mean age of 32.3 ± 6.5 years at the time of surgery. The mean follow-up time was 51.9 ± 34.5 months. There were 39 subjects in Group 1 (45.9%), 20 in Group 2 (23.5%), and 26 in Group 3 (30.6%). About half of all subjects expressed “some” to “a lot of” concern that their hip pain could get worse during pregnancy (49.4%), and about half had “no concern” that hip arthroscopy would affect the health of their fetus/baby (54.1%). Reproductive-age females undergoing hip arthroscopy for FAIS generally consider the procedure to be safe with respect to future pregnancy outcomes. Full article

Atypical teratoid-rhabdoid tumor (AT/RT) is a rare but one of the most aggressive embryonal tumors of the central nervous system (CNS), most often occurring in children under 3 years of age. AT/RT accounts for about 1–2% of all CNS neoplasms and has a very poor prognosis, high risk of secondary tumor development, recurrence and/or metastasis in patients in remission and limited therapeutic potential. The clinical manifestations are usually symptoms of increased intracranial pressure. The mainstay of tumor treatment is complex chemotherapy combined with radiation therapy. A clinical case of sequential occurrence of two cancers (AT/RT and leukemia) in a 3-year-old girl is presented. Full article

Trigeminal neuralgia (TN) is a chronic condition that is typically caused by a blood vessel exerting pressure on the V cranial nerve at the root entry zone. The gold standard for TN treatment is microvascular decompression (MVD). This illustrative case shows an advanced surgical technique that combines the use of an exoscope and endoscope to treat TN with an innovative addition of intraoperative indocyanine green (ICG) control that can improve arterial and venous compression identification. The use of exoscopes and endoscopes, offering 360° root assessment, represents a significant evolution in surgical approaches. Enhanced visualization with ICG aided in identifying complex neurovascular conflicts, improving decompression accuracy. The use of both exoscope and endoscope, offering a 360° root assessment, represents a significant evolution in the microsurgical approach of TN. The additional use of ICG monitoring in a dynamic mode may be useful in identifying the complex arteriovenous form of neurovascular conflict. The endoscopically assisted exoscopic surgery with the intraoperative use of ICG for MVD of the trigeminal nerve can improve the identification of complex impingements underlining its effectiveness and potential in neurosurgical practice. Full article

The uterine tourniquet is often not used to reduce intraoperative blood loss due to controversial opinions in the literature. The objective was to evaluate the effectiveness of this procedure in laparotomic myomectomy. This is a retrospective, monocentric case-control study, including patients who underwent laparotomic myomectomy and were categorized into the Tourniquet Group (A) and No Tourniquet Group (B). The blood loss outcomes were compared. Intra-operative blood loss in Group A was 275 ± 200 mL, while in Group B was 410 ± 390 mL (p = 0.11). Notably, five patients in the No Tourniquet Group lost more than 1000 mL of blood and required blood transfusion, while no such cases were reported in the Tourniquet Group. Furthermore, the decrease in hemoglobin post-procedure was statistically significant, favoring Group A with a decrease of 1.9 ± 0.7 g/dL compared to Group B’s 2.8 ± 2.2 g/dL (p = 0.04). The use of the Foley catheter as a tourniquet during laparotomic myomectomy may represent a remarkable tool that profoundly impacts the surgical process by substantially reducing blood loss. Its use may play a role in significantly diminishing the likelihood of requiring blood transfusions, enhancing patient safety and outcomes, and should be systematically adopted. Full article

Laryngoscopy for tracheal intubation has been developed for many decades. Among various conventional laryngoscopes, videolaryngoscopes (VLs) have been applied in different patient populations, including difficult airways. The safety and effectiveness of VLs have been repeatedly studied in both normal and difficult airways. The superiority of VLs then has been observed and is advocated as the standard of care. In contrast to laryngoscopy, the development of video-assisted intubating stylet (VS, also named as styletubation) was noticed two decades ago. Since then, sporadic clinical experiences of use have appeared in the literature. In this review article, we presented our vast use experiences of the styletubation (more than 55,000 patients since 2016). We found this technique to be swift (the time to intubate from 3 s to 10 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction and fast learning curve for the novice trainees) in both normal and difficult airway scenarios. We, therefore, propose that the styletubation technique can be feasibly applied as universal routine use for tracheal intubation. Full article

Spine and hip abnormalities frequently occur together in most of the orthopedic population; therefore, both of these abnormalities impact the outcomes of the modalities that are being used. Few studies have reported reduced dislocation and revision rates with the use of dual-mobility cups (DMCs) in high-risk lumbar spine fusion (LSF) patients undergoing primary total hip arthroplasty (THA). This study aims to clarify the relationship between pre-existing lumbar spinal fusion and the outcomes of THA with dual-mobility constructs. We systematically reviewed the current literature through several online databases following PRISMA protocol and the Cochrane Handbook for Systematic Reviews of Interventions. We used the methodological index for non-randomized studies (MINORS) to evaluate the methodological quality of the included trials. Four studies examined the feasibility and effectiveness of dual-mobility cups in patients undergoing primary THA with prior LSF. Two studies were conducted in the United States, while the other two originated in Finland and France, respectively. The included studies enrolled 284 patients. Most of these patients had instrumented fusions. Seventy-eight percent of patients received one- or two-level fusions. The average age across the studies was 68.22 and the mean body mass index was 28. No cases of postoperative DMC implant dislocations were identified. The incidence of postoperative complications was 6% (10/173), including deep venous thrombosis, periprosthetic loosening, infection, and fracture, greater trochanteric fracture, and superficial wound infections. Most included studies had some methodological limitations, with an average MINORS score of 10.5 ± 5.8. The use of dual-mobility cups in these high-risk patients undergoing total hip arthroplasty may lead to reduced dislocation rates and postoperative complications. Further long-term follow-up studies are warranted to support these findings. Full article

We aimed to study the relationship between mortality following emergency laparotomy (EL) in elderly patients and admission to a hospital facility, hypothesizing that patients initially admitted to a general surgery service have a better outcome. A retrospective review of the medical records of all the elderly patients (≥65 years) who underwent EL over three years was conducted in a single tertiary medical center. The outcomes evaluated include postoperative morbidity, mortality, discharge destination, and readmission. A total of 200 patients were eligible for this study; 106 (53%) were male, with a mean age of 77 ± 8.3 years. The mortality rate was 29.5% (59 patients), and 55% of all patients were discharged home after initial admission. Bowel obstruction was the most common indication for surgery (91, 45.5%). Patients undergoing an operation from non-general surgical services had higher readmission, unfavorable discharge and mortality rates, a greater incidence of stoma formation, and required a tracheostomy or were TPN-dependent (all p < 0.001). The mortality rate is higher in elderly patients needing an EL when initially admitted through a non-general surgery service. A correct and rapid initial diagnosis and decision are crucial when treating elderly individuals; initial admission to a general surgery service increases the probability of discharge home. Full article