Surgical Techniques Development

Purpose: Inguinal hernia repair is a common surgical procedure. It was widely reported worldwide during the COVID-19 pandemic. To manage the lack of anesthesiologists, we have introduced a new protocol to manage inguinal hernia repair. Methods: This protocol is the result of a strong collaboration between surgeons and anesthesiologists. It was based on EHS recommendations and the well-described percutaneous ilioinguinal–iliohypogastric and genitofemoral nerves block. Results: More than 400 patients have been treated at our institution. The application of the protocol has led to a sensible reduction in initially planned spinal anesthesia. The complications traditionally related to spinal anesthesia have not been reported in 80% of the patients. Only three patients required the infusion of atropine or flumazenil without the need to involve anesthesiologist. Conclusion: The application of our protocol seems promising. Preliminary results have shown the safety and efficacy of percutaneous ilioinguinal–iliohypogastric and genitofemoral nerves block. The combination of this kind of anesthesia with wound protector and adequate postoperative pain control can lead to a reproducible system avoiding the not strictly necessary presence of an anesthesiologist. The changes that have occurred in the healthcare system in recent years should be new opportunities for the improvement of resources and results. Full article

Background: There is sparse literature on the technique of single-stage anterior discectomy fusion and posterior decompression and flavectomy using the biportal endoscopic technique. Methods: Single-stage anterior discectomy fusion and posterior biportal endoscopic decompression and flavectomy apply to cervical myelopathy at a single level with an anterior disc and posterior ossified ligamentum flavum complex. Anterior discectomy and fusion were performed in the usual fashion in the supine position, and subsequently, posterior biportal endoscopic decompression was carried out after turning the patient prone. Conclusion: Single-stage anterior discectomy fusion and posterior biportal endoscopic decompression and flavectomy are good alternatives for circumferential decompression with myelopathy Full article

Background and Objectives: Parotid cancer (PC), when treated surgically, may have associated damage to the functionality of the facial nerve. The role of radiotherapy in the recovery of facial motricity remains controversial. This study aimed to evaluate the impact of radiotherapy (RT) on facial nerve functionality in patients who underwent parotidectomy and facial nerve microsurgical reconstruction. Materials and Methods: Four groups of patients were composed: (a) those who underwent parotidectomy without facial nerve reconstruction and RT; (b) those with nerve reconstruction and without RT; (c) those without nerve reconstruction and RT; and (d) those with nerve reconstruction and RT. Results: 49 patients were male, and 43 were female. A total of 89 underwent parotidectomy, 45 partials, and 44 total. Thus, in nine patients, the sural nerve was used for microsurgical reconstruction. Moreover, 48 patients had a normal facial pattern, 15 with paresthesia, and 29 with permanent paralyses after the House–Brackmann (HB) scale evaluation. Conclusions: The evaluation of nerve functionality after parotidectomy by the House–Brackmann scale is a feasible way to evaluate facial motricity that has already decreased in these patients. Finally, longitudinal studies must be performed to clarify the role of each therapy in the multimodal approach and their clinical impact in facial nerve function. Full article

Osteoarthritis (OA) is one of the main causes of disability worldwide and is caused by the progressive degeneration of joint tissues, ultimately leading to chronic pain and loss of function. Intraarticular delivery of mesenchymal stromal cells, such as adipose-derived stromal cells (ASCs), is being actively investigated due to their trophic properties observed in both preclinical and clinical studies. However, cell expansion and handling involve costly and time-consuming processes that limit their application. Recently, several devices and kits have been developed to isolate and process the stromal vascular fraction (SVF), a high biologically active compound of the adipose tissue, right at the patient’s bedside. In this study, we introduce a novel technique to obtain an SVF graft with a high content of ASCs for intraarticular injection directly from liposuction and with minimal equipment. In this technical note, we describe in detail the steps of the surgical technique as well as strategies to avoid common pitfalls and complications. Full article

Lacrimal gland prolapse is an important diagnosis to consider in patients with lateral upper eyelid fullness. Prolapse of the lacrimal gland is the descent of the lacrimal gland into the upper eyelid. It can result in blepharoptosis and a bulging “frog-eyed” appearance. This is a case report of lacrimal gland prolapse in a 19-year-old female patient treated by suture repositioning of the glands in an outpatient surgical setting. We report on non-recognition of the prolapse and in the absence of essential surgical correction, in addition to the aesthetic disorders often reported, worsening of functional symptoms such as epiphora with major discomfort. Prolapse in young patients has not been reported in the international literature consulted, E&OE. Full article

Introduction: Hyperbaric oxygen therapy (HBOT) has been used over the past six decades to treat multiple conditions. This systematic review aims to identify and evaluate the clinical outcomes of hyperbaric oxygen therapy in the field of plastic, reconstructive, and aesthetic surgery, found in the literature from the year 2000 to the present. Methods: A systematic review of the literature focused on the conceptual and methodological aspects of the PRISMA Declaration. The search for clinical trials focused on the results of hyperbaric therapy in plastic, reconstructive, and cosmetic surgery. The Newcastle–Ottawa scale suggested by the Cochrane manual was applied to each study. The study was carried out with a defined protocol and was registered in PROSPERO, with code CRD42022301261. Results: From the 170 articles identified, 6 were selected. Five of them showed that hyperbaric oxygen therapy favored the reduction of the size of skin ulcers and increased the formation of granulation tissue (two trials; p < 0.05), increased the partial pressure of transcutaneous oxygen in patients with free flaps (one trial; p < 0.001), reduced perfusion in keloid scarring disorder (one trial; p < 0.01), and accelerated both the fading of melanin pigmentation and the decrease in age spot size (one trial; p < 0.05). The methodological quality was moderate in all cases because there was no blinding method reported. One study failed to find differences in flap survival, time to resolution of venous congestion, resolution of edema, and postoperative recovery period (p > 0.05). Conclusions: Hyperbaric oxygen therapy has been increasingly used in the field of plastic and reconstructive surgery, and has shown potential benefits in promoting wound healing, reducing the risk of infection, and improving the survival of tissues used in reconstructive procedures. Further research with more rigorous clinical trials is needed to fully understand the efficacy and optimal use of this therapy in the field of plastic and reconstructive surgery. Full article

Cytoreductive surgery (CRS) is the cornerstone of treating advanced ovarian cancer. Approximately 60–70% of patients with advanced ovarian cancer will have involvement in the upper abdomen or the supracolic compartment of the abdominal cavity. Though the involvement of this region results in poorer survival compared, complete cytoreduction benefits overall survival, making upper-abdominal cytoreduction an essential component of CRS for advanced ovarian cancer. The upper abdomen constitutes several vital organs and large blood vessels draped with the parietal or visceral peritoneum, common sites of disease in ovarian cancer. A surgeon treating advanced ovarian cancer should be well versed in upper-abdominal cytoreduction techniques, including diaphragmatic peritonectomy and diaphragm resection, lesser omentectomy, splenectomy with or without distal pancreatectomy, liver resection, cholecystectomy, and suprarenal retroperitoneal lymphadenectomy. Other procedures such as clearance of the periportal region, Glisson’s capsulectomy, clearance of the superior recess of the lesser sac, and Morrison’s pouch are essential as these regions are often involved in ovarian cancer. This manuscript covers the surgical anatomy of the upper abdomen, the techniques and therapeutic rationale of upper-abdominal cytoreduction, and specific measures for perioperative management of these patients. The main focus is the description of various peritonectomies and regional lymphadenectomies. Full article

Background: Acromioclavicular (AC) dislocation, one of the most common shoulder joint injuries, can be treated by several surgical methods. However, there are still few records about the treatment quality. This study aims to describe the outcomes of three surgical methods for acromioclavicular dislocation treatment at Viet Duc University Hospital, Vietnam. Methods: A cross-sectional study was conducted on 80 patients diagnosed with AC. We retrospectively collected data in the medical records and re-examined the patients. Results: There was no difference between the three groups of surgical approaches relating to the patient’s characteristics, except for the time from the accident to hospital admission. The median length of stay after surgery was highest in the Hook plate group (median (IQR) = 5(2) days), while it was lowest in the K-wire group (median (IQR) = 3(1) days) (p < 0.05). There is statistical significance in the difference of coracoclavicular distance between pre and post-operation in all three surgical method groups (p < 0.001). Conclusion: All of the methods—Hook plate, K-wire, and TightRope—were associated with optimistic outcomes and restored initial anatomy. While the three surgical methods are both safe and effective, the K-wire method is associated with a shorter length of stay and might be economical. Full article

Ameloblastoma is a benign yet locally invasive odontogenic neoplasm, characterised by slow growth and painless swelling. The treatment for ameloblastoma varies from curettage to en bloc resection, with recurrence commonly occurring. The safety margin of resection is hence essential to avoid recurrence. Understanding the three-dimensional anatomy for reconstruction of mandibular defects after tumour resection often poses problems for head and neck surgeons. Historically, various autografts and alloplastic materials have been used in the reconstruction of these types of defects. Over time, advances in technology with computed tomography scanners and three-dimensional images enhance the surgical planning and management of maxillofacial tumours. The development of new prototyping systems provides accurate 3D biomodels on which surgery can be simulated, especially in cases of ameloblastoma, in which the safety margin is vital for the clinical outcome. The objective of this paper was to report a clinical case of employing these methodologies for reconstruction after an extensive mandibular resection. The clinical outcomes were observed. A case of follicular ameloblastoma of the mandible is depicted in the following paper, where a 3D biomodel was used throughout the surgery. A 3D printed patient-specific titanium implant was manufactured and placed intraoperatively for reconstruction. The treatment had satisfactory postoperative results without complications. Titanium implants being bioinert, customisable and easily workable, especially with the help of 3D virtual planning techniques, can be considered as ideal alloplastic materials for mandibular reconstruction. Full article

Objective: To explore the surgical effect of three-dimensional (3D) image reconstruction technology in pancreatoduodenectomy. Methods: The clinical records of 47 cases who underwent pancreatoduodenectomy between January 2018 and December 2019 at the department of hepatobiliary surgery of the General Hospital of Ningxia Medical University were retrospectively examined, including 23 males and 24 females, with an average age of 55.00 ± 10.06 years. All patients underwent enhanced computed tomography (CT), and the 3D images were reconstructed by uploading the CT imaging data. The pre-operation evaluation and treatment strategy were planned according to CT imaging and 3D data, respectively. The change of treatment strategy based on 3D evaluation, actual surgical procedure, tumor volume measured by 3D model, actual tumor volume, variants of hepatic artery, operation time, intraoperative blood loss, post-operation hospital stay and post-operation complications was recorded. Results: The treatment strategies were changed after 3D visualization in 10 (21.3%) out of 47 patients because of blood vessel and organ invasion by tumor. The surgical procedure was changed in three cases, and the surgical procedure was optimized and improved in seven cases. All surgical plans based on 3D visualization technology were matched with the actual surgical procedures. Tumor volume measured by 3D model was 19.69 ± 23.47 mL, post-operation actual tumor volume was 17.07 ± 20.29 mL, with no significant difference between them (t = 0.54, p = 0.59). Pearson’s correlation analysis showed statistical significance (r = 0.766, p = 0.00). The average operation time was 4.85 ± 1.75 h, median blood loss volume was 447.05 (50–5000) mL, and post-operation hospital stay was 26.13 ± 11.13 days. Six cases had pancreatic fistula, two cases had biliary leakage, and four cases had delayed gastric emptying. Ascites and pleural effusion was observed in three cases. Conclusions: 3D visualization technology can offer a precise and individualized surgical plan before operation, which might improve the safety of pancreatoduodenectomy, and has application value in preoperative planning. Full article

Unilateral biportal lumbar endoscopic interbody fusion is a relatively new technique in the field of minimally invasive spine surgery. It combines the benefits of preservation of the normal anatomy of the spine with direct visualization of the decompression of neural elements and endplate preparation for fusion. This results in high union rates and excellent outcomes for patients with back pain and lumbar spinal stenosis from spondylolisthesis while reducing the risk of injuries to the neural elements, endplate fractures and the theoretical rate of adjacent segment disease from disruption of the musculature. In this paper, we describe the steps and technical pearls pertaining to this technique and methods to avoid common pitfalls and complications. In conclusion, this technique would be a good tool in the armamentarium of a spinal surgeon specializing in minimally invasive spinal surgery. Full article

This study aims to demonstrate the use of surgical ostioplasty of the left main coronary artery as an alternative technique to the conventional use of coronary artery bypass grafting for the treatment of left main stem-isolated ostial stenosis. From 2002 to 2021, five patients—three women (60%) and two men (40%)—presented with a history of angina pectoris and were diagnosed with isolated stenosis of the coronary ostia associated with normal distal coronary arteries. Pre-operative cardiac catheterization and echocardiography were performed to aid in the diagnosis. The patients were submitted to surgical ostioplasty with a posterior approach using a saphenous patch. There were no hospital deaths or myocardial infarctions during the post-operative period. The mean cardiopulmonary bypass time was 82 min (range, 70–95 min), and the mean aortic-clamp time was 62 min (range, 55–75 min). The average time of hospitalization was 6.2 days (range, 4–18 days). Patients with isolated stenosis of the coronary ostia associated with normal distal coronary arteries may be submitted to left main coronary artery ostioplasty as an alternative to coronary artery bypass grafting, the traditional surgical technique for this pathology. Full article

Objective: Femoral anteversion is an important parameter that can prevent complication following total hip arthroplasty (THA) caused by improper positioning of the implant. However, assessing the femoral anteversion can be challenging in situations with significant defect of the femoral neck. In this study, the lesser trochanter version was nominated as alternative parameter to femoral anteversion. So, the main objective of this study is to determine whether the femoral anteversion correlates with the lesser trochanter version. Design: Retrospective study. Methods: Three-dimensional images of 100 femora were generated and their femoral anteversion and lesser trochanter version was measured. Correlation between the parameters were calculated. Results: The mean lesser trochanter version was 38.54° ± 7.86° (mean ± SD), while the mean femoral anteversion was 11.84° ± 10.06°. The lesser trochanter version was inversely correlated with the femoral anteversion with a correlation coefficient of −0.72. Conclusions: The lesser trochanter should be considered as an additional bony landmark to assess proper implant positioning in THA. Full article

Free flaps from the lower abdomen represent the workhorses of modern autologous, microvascular breast reconstruction. Rare signs of venous congestion often become evident during the primary index operation, but a secondary shift of the initially dominant drainage of the DIEV system to the SIEV system with consequent malperfusion is a feared, rare event requiring urgent decision, and complex skill using vein grafts and additional anastomosis to restore a sufficient venous outflow. For secondary anastomosis of the SIEV, especially in stacked flaps, a vein graft to the DIEV or retrograde IMV may be necessary, but this requires an additional donor site, thus prolonging procedure time during the emergency operation and resulting in additional scars of the graft’s donor site. We report on a versatile, easy technique of scheduled inframammary fold banking of the dissected, flushed, and clipped non-dominant superficial epigastric vein (SIEV) in unilateral autologous breast reconstruction during the index operation. The banked graft may service as an easy and convenient accessible vein graft in the rare event of secondary shifting of the initial dominant drainage of the DIEV to the SIEV system with the need for urgent re-operation. We retrospectively evaluated the management and outcome of all suitable patients receiving autologous breast reconstruction with a unilateral abdominal DIEP or MS-Tram flap accompanied by banking of the SIEV in the breast pocket between 2017 and 2020 in the present study. In two out of 42 patients (4.8%) receiving autologous breast reconstruction with an abdominal DIEP or MS-TRAM flap with banking of the SIEV in the breast pocket, secondary malperfusion of the flap with progressive venous congestion occurred during the first 48 h perioperatively, between 2 and 37 (mean: 19.5) hours after skin closure. In both cases malperfusion was due to secondary SIEV system dominance, and the banked vein was used as an interpositional graft to the retrograde IMV (case 1) or the DIEV (case 2). Revision surgery lasted between 95 and 121 (mean: 108) minutes without the need for further vein graft harvesting, and further healing was uneventful. Based on the limited cases, inframammary fold banking of the non-dominant SIEV is a versatile, beneficial, and feasible concept with scarce additional dissection time and can be done in all unilateral breast reconstructions to have a reliable graft for emergency re-exploration. It is a useful approach in the context of spare part surgery and tissue banking to safeguard against the rare instance of venous congestion and need for an interpositional graft. Full article

The annual congress of the Italian Association of Plastic Aesthetic Surgery (AICPE) is one of the most relevant conference meetings in Europe concerning aesthetic plastic surgery due to the number of participants and as parterre of invited speakers chosen for their renowned scientific value [...] Full article

Patients will typically present symptoms of chronic post-radiation colitis and proctitis 8–12 months after finishing their treatment. Endoscopic methods play the main role the treatment of bleeding caused by post-radiation colitis and proctitis. Surgical treatment is required for remained approximately 10% of patients. Here we present a 64 year old female with metastatic breast cancer, who was referred to us for intractable rectal bleeding. Total colonoscopy and rigid rectosigmoidoscopy revealed proctitis, rectal and sigmoidal telangiectasis, multiple necrotic ulcers between 15 to 30 cm from the anal verge, and also huge ishemic ulcer with patchy necrotic areas about 10 cm from the anal verge. This abnormal irradiated part was resected and then mucosectomy of the remnant rectum, both transabdominally and transanally was done. We performed pull-through technique of normal proximal colon to anal region through the remnant rectal wall and finally did coloanal anastomosis. Diverting stoma was not made because of anastomosis in anal region. With this technique we can achieve benefits such as avoidance of harsh dissection in a frozen pelvis and its consequences, we can avoid intra-abdominal anastomosis, there is no need to a diverting stoma and, most important of all, definite bleeding control. Full article