Suture techniques Research Papers - Academia.edu (original) (raw)

In a prospective study we used the change of central and peripheral (12 o'clockposition) corneal thickness (CT) after no-stitch small incision cataract surgery as a parameter of tissue traumatisation (33 eyes) and compared the values to a... more

In a prospective study we used the change of central and peripheral (12 o'clockposition) corneal thickness (CT) after no-stitch small incision cataract surgery as a parameter of tissue traumatisation (33 eyes) and compared the values to a series of cases (32 eyes) with conventional 3.5 mm scleral step incision. In both groups the peripheral measurements showed a higher increase in corneal thickness than the central. After 1 month all eyes regained their central preoperative thickness. Increase in corneal thickness (ACTc, ACTp) after the different postoperative periods were correlated. The values of the central cornea showed no significant difference between the two groups. 1, 7 and 30 days after surgery the increase of peripheral CT was significantly higher in the no-stitch group. This fact was underlined by the clinical aspect at the slit lamp and is due to the anatomical and surgical characteristic of this procedure. One month postoperatively there was no increased endothelial cell loss in the no-stitch group (3%). No-stitch cataract surgery surgery provides a lot of intra-and postoperative advantages. The problem of increased swelling of the peripheral corneal entry seems to be a secondary one as corneal thickness decreases with time. Concerning the prospective endothelial cell loss it is mandatory to study the long term results.

Purpose: To report a new technique of arthroscopic biceps tenodesis using bioabsorbable interference screw fixation and the early results. Type of Study: Prospective, nonrandomized study. Methods: Technique: The principle of arthroscopic... more

Purpose: To report a new technique of arthroscopic biceps tenodesis using bioabsorbable interference screw fixation and the early results. Type of Study: Prospective, nonrandomized study. Methods: Technique: The principle of arthroscopic biceps tenodesis is simple: after biceps tenotomy, the tendon is exteriorized and doubled on a suture; the biceps tendon is then pulled into a humeral socket (7 or 8 mm ϫ 25 mm) drilled at the top of the bicipital groove, and fixed using a bioabsorbable interference screw (8 or 9 mm ϫ 25 mm) under arthroscopic control. Patients: 43 patients treated with this technique between 1997 and 1999 were followed-up for at least 1 year. The technique was indicated in 3 clinical situations: (1) with arthroscopic cuff repair (3 cases), (2) in case of isolated pathology of the biceps tendon with an intact cuff (6 cases), and (3) as an alternative to biceps tenotomy in patients with massive, degenerative and irreparable cuff tears (34 cases). The biceps pathology was tenosynovitis (4 cases), prerupture (15 cases), subluxation (11 cases), and luxation (13 cases). Results: The absolute Constant score improved from 43 points preoperatively to 79 points at review (P Ͻ .005). There was no loss of elbow movement and biceps strength was 90% of the strength of the other side. Two patients, operated on early in the series, presented with a rupture of the tenodesis. In both cases the bicipital tendon was very friable and the diameter of the screw proved to be insufficient (7 mm). No neurologic or vascular complications occurred. Conclusions: Arthroscopic biceps tenodesis using bioabsorbable screw fixation is technically possible and gives good clinical results. This technique can be used in cases of isolated pathologic biceps tendon or a cuff tear. A very thin, fragile, almost ruptured biceps tendon is the technical limit of this arthroscopic technique.

Management options for posteriorly dislocated posterior chamber intraocular lenses include observation, removal, exchange, and repositioning. Many microsurgical techniques have been developed for repositioning posterior chamber implants.... more

Management options for posteriorly dislocated posterior chamber intraocular lenses include observation, removal, exchange, and repositioning. Many microsurgical techniques have been developed for repositioning posterior chamber implants. These include repositioning into the ciliary sulcus without suturing if adequate posterior capsule support remains, iris fixation suturing techniques, and scleral fixation suturing techniques. The indications, timing, and techniques for intervention are reviewed in a series of 32 cases with posteriorly dislocated posterior chamber implants. A final visual acuity of 20/40 or better was achieved in 15 (79%) of 19 IOL repositioned cases, in 6 (75%) of 8 IOL exchanged cases, and in 1 (33%) of 3 IOL removed cases. In two patients observed without surgery, final visual acuity was 20/25 and 20/300, respectively.

The battlefield surgeon is faced with challenges in the management of leg and foot compartment syndrome because the condition's pathophysiology, diagnostic modalities, and treatment methods all involve controversy. Blast injury,... more

The battlefield surgeon is faced with challenges in the management of leg and foot compartment syndrome because the condition's pathophysiology, diagnostic modalities, and treatment methods all involve controversy. Blast injury, high-velocity gunshot wounds, and blunt trauma associated with combat operations cause injuries that may induce compartment syndrome. If untreated, muscle and nerve necrosis may occur. Subsequent myoneural fibrosis, contracture, infection, amputation, and systemic complications are all possible. However, compartment syndrome and its sequelae can be prevented or mitigated by prompt intervention to maintain adequate tissue oxygenation. At present, recommendations for a low threshold for fasciotomy are maintained to avoid missing the diagnosis; however, this exposes casualties to the risks of fasciotomy in false-positive cases. The incidence of compartment syndrome and limbs at risk in combat casualties requiring evacuation is estimated to be 15%. 1 In recent United States' conflicts, severe extremity trauma caused by blast injuries has been a common presentation resulting in more than 71% of the total number of extremity injuries and accounts for 86% of those requiring fasciotomy. 1-4 Exploding ordnance causes significant

Objective: To evaluate the short-term outcomes of hemorrhoidectomy performed using the LigaSure vessel sealing device (Valleylab, Boulder, Colorado) or the conventional approach. Data Sources: MEDLINE, EMBASE, Ovid, and Cochrane databases... more

Objective: To evaluate the short-term outcomes of hemorrhoidectomy performed using the LigaSure vessel sealing device (Valleylab, Boulder, Colorado) or the conventional approach. Data Sources: MEDLINE, EMBASE, Ovid, and Cochrane databases for studies published between 2002 and 2006. Study Selection: Randomized controlled trials published between 2002 and 2006 comparing short-term outcomes for LigaSure vs conventional hemorrhoidectomy. Data Extraction: Operative parameters, short-term complications, and postoperative recovery. Trials were assessed using a modified Jadad score. Random-effects metaanalytical techniques were used in the analysis. Data Synthesis: Nine randomized controlled trials with matched selection criteria reporting on 525 patients, of whom 266 (50.7%) underwent LigaSure and 259 (49.3%) underwent conventional hemorrhoidectomy. Operative time (weighted mean difference [WMD], −8.67 minutes; 95% confidence interval [CI], −15.34 to −2.00 minutes), blood loss (WMD, −23.08 mL; 95% CI, −27.24 to −18.92 mL), and pain the day after the operation measured by the visual analog scale (WMD, −2.31; 95% CI, −3.37 to −1.26) were significantly reduced following LigaSure hemorrhoidectomy. There was a decrease in time taken to return to work or normal activity (WMD, −3.49 days; 95% CI, −7.40 to 0.43), which was of marginal significance (P=.08). Incidence of postoperative hemorrhage was comparable as was incidence of anal stenosis and fecal and flatus incontinence between the 2 groups.

The frequency of malignant adenomas of the papilla figures between 15 and 30%. Villous adenoma is considered to be a premalignant lesion. Resection of the papilla is indicated in large tubular and small tubulovillous adenoma.... more

The frequency of malignant adenomas of the papilla figures between 15 and 30%. Villous adenoma is considered to be a premalignant lesion. Resection of the papilla is indicated in large tubular and small tubulovillous adenoma. Ampullectomy, however, is mandatory in villous adenoma with severe dysplasia and large villous or tubulovillous adenoma. If villous adenoma with a low-risk pT1 N0 M0 G1/2-cancer is treated by ampullectomy, local lymph dissection should also be performed. Ampullectomy includes extirpation of the ampulla of Vater and reinsertion of the common bile duct and the pancreatic main duct into the duodenal wall. Hospital mortality after ampullectomy is less than 0.4%, and surgical morbidity, e.g., cholangitis, below 10%.

Endoscopic treatment of GERD is still in its infancy, however the potential benefits of an endoscopic treatment for GERD are great. These procedures can be performed on an outpatient basis, without the risks of general anesthesia. The... more

Endoscopic treatment of GERD is still in its infancy, however the potential benefits of an endoscopic treatment for GERD are great. These procedures can be performed on an outpatient basis, without the risks of general anesthesia. The absence of abdominal incisions eliminates the morbidity of wound infections and hernia formation. The procedures are certainly less painful than laparoscopic or open surgery for reflux disease. These procedures might even be more cost effective than long-term acid suppression. These benefits make endoscopic treatment for reflux disease an appealing alternative. While the ideal endoscopic therapy has not been developed, all of these approaches have promise for the future and with further study the role of endoscopic therapy for GERD will continue to be defined.

Hand suture microanastomosis is a difficult procedure. This report describes a simplified microanastomosis using cuff and glue apparatus. Model: Vena cava and intestine of rat were sectioned. The distal margin was introduced into an... more

Hand suture microanastomosis is a difficult procedure. This report describes a simplified microanastomosis using cuff and glue apparatus. Model: Vena cava and intestine of rat were sectioned. The distal margin was introduced into an everted cuff covering the outer wall and fixed to the base of the tube by three stitches. The proximal segment was inserted into the cuff system and an encircling ligature was performed to attach both margins to the cuff. Proximal margin below ligature was pulled up exposing both intimae where glue was deposited. The proximal margin was pulled down, sealing the borders by glue adhesion. Ligatures fixing the system were sectioned and the cuff was removed. Anastomosis acquired a waveform shape, obtaining ideal intima-intima union and improving the healing process. After short training, this anastomosis can be performed within 10 min. This technique avoids cuff foreign body reaction, simplifies microanastomosis research, and may improve glue technology for tissue anastomosis.

This biomechanical study compared the fixation characteristics of horizontally or vertically implanted FasT-Fix devices (Smith & Nephew, Endoscopy Division, Andover, MA) consisting of two 5-mm PLLA suture T-bar anchors with a pretied... more

This biomechanical study compared the fixation characteristics of horizontally or vertically implanted FasT-Fix devices (Smith & Nephew, Endoscopy Division, Andover, MA) consisting of two 5-mm PLLA suture T-bar anchors with a pretied self-sliding knot (No. 0 nonabsorbable, USP, braided polyester suture material) and the RapidLoc device (Mitek Surgical Products, Westwood, MA) consisting of a PLLA T-bar anchor or "backstop," a connecting suture (No. 2 nonbiodegradable Ethibond; Ethicon, Somerville, NJ), and a PLLA grommet, for repairing posterior third lesions in human menisci. Type of Study: Controlled laboratory biomechanical study. Methods: After repair of a vertical longitudinal meniscus lesion with either vertically or horizontally implanted FasT-Fix devices or RapidLoc devices, 3 groups of 6 specimens underwent cyclic loading (5 mm/minute, cycling between 5 and 50 N at 1 Hz for 500 cycles) before load to failure testing on a servo hydraulic device. One-way analysis of variance and Tukey HSD post hoc tests were used to evaluate group differences (P Ͻ .05). Results: The vertical FasT-Fix device group (3.2 Ϯ 0.49 mm) had less displacement after cyclic testing than either the horizontal FasT-Fix (4.4 Ϯ 0.73 mm, P ϭ .003) or the RapidLoc (4.6 Ϯ 0.22 mm, P ϭ .002) device groups. The vertical FasT-Fix device group had greater stiffness during cyclic testing (14.4 Ϯ 2.1 N/mm) than the horizontal FasT-Fix (10.4 Ϯ 1.6 N/mm, P ϭ .0001) or the RapidLoc (9.7 Ϯ 0.44 N/mm, P ϭ .0001) device groups. During load to failure testing, the vertical FasT-Fix group (125.3 Ϯ 39 N) had 28% greater strength than the horizontal FasT-Fix device group (89.7 Ϯ 14 N, P ϭ .02) and 30% greater strength than the RapidLoc device group (87.1 Ϯ 13 N, P ϭ .028), whereas displacement and stiffness did not show statistically significant group differences. Conclusions: The vertical FasT-Fix group had superior biomechanical characteristics for meniscal fixation during cyclic and load to failure testing compared with horizontal FasT-Fix or RapidLoc devices. Clinical Relevance: Although the RapidLoc devices provided fixation characteristics comparable to horizontally implanted FasT-Fix devices, vertically implanted FasT-Fix devices may provide superior all-inside fixation.

Introduction: Oesophagoscopy is usually a safe procedure to localise and remove ingested foreign bodies, however, unexpected complications may develop during this procedure. In this case report we discuss iatrogenic aortic injury, which... more

Introduction: Oesophagoscopy is usually a safe procedure to localise and remove ingested foreign bodies, however, unexpected complications may develop during this procedure. In this case report we discuss iatrogenic aortic injury, which developed during oesophagoscopy, and its immediate treatment. Case report: A six-year-old male patient was admitted to hospital with symptoms of having ingested a foreign body. Oesophagoscopy was carried out and the foreign body was visualised at the second constriction of the oesophagus. During this procedure, profuse bleeding occurred. Subsequently, a balloon dilator was placed to control bleeding in the oesophagus. Thoracic contrast tomography revealed thoracic aortic injury. Open surgical aortic repair was immediately carried out on the patient and the oesophageal hole was primarily repaired. The patient was discharged on postoperative day 15 with a total cure. Conclusion: Although oesophagoscopy is a safe, easily applied method, it should be kept in mind that fatal complications may occur during the procedure. This procedure should be done in high-level medical centres, which have extra facilities for managing complications.

Purpose Extensor tendon injuries are common; however, relatively few studies have evaluated extensor tendon repair methods. The purpose of this study was to investigate the properties of the running-interlocking horizontal mattress repair... more

Purpose Extensor tendon injuries are common; however, relatively few studies have evaluated extensor tendon repair methods. The purpose of this study was to investigate the properties of the running-interlocking horizontal mattress repair method with regard to tendon shortening, stiffness, strength, and time needed to perform the repair, compared with the modified Bunnell method and the augmented Becker method. Methods Twenty-four extensor tendons from 8 fresh-frozen cadaveric hands were harvested from zone 6. The harvested tendons were randomly assigned into 1 of 3 repair groups: augmented Becker, modified Bunnell, and running-interlocking horizontal mattress repair methods. The running-interlocking horizontal mattress repair combines a running suture with an interlocking horizontal mattress suture. Each repaired tendon was measured for length before and after repair and tested for stiffness, ultimate load to failure, and time required to perform the repair. Results The running-interlocking horizontal mattress repair was significantly stiffer (8,506 N/m) than the augmented Becker (5,971 N/m) and the modified Bunnell (6,719 N/m) repairs. The running-interlocking horizontal mattress repair resulted in significantly less shortening (1.7 mm) than the augmented Becker (6.2 mm) and modified Bunnell (6.3 mm) repairs. The running-interlocking horizontal mattress repair took significantly less time to perform without a significant difference in the ultimate load to failure (running-interlocking horizontal mattress repair, 51 N; augmented Becker, 53 N; modified Bunnell, 48 N). Conclusions The running-interlocking horizontal mattress repair is significantly stiffer and faster to perform than either the augmented Becker or the modified Bunnell repairs, and it results in less shortening than either of these methods. The running-interlocking horizontal mattress repair should be strong enough to withstand some early motion.

Absorbable sutures [4-6] [Table 1] are placed into subcutaneous tissue to eliminate dead space and into the dermis to minimize tension during wound healing. [4] Absorbable sutures must be placed well into dermis and subcutaneous tissue to... more

Absorbable sutures [4-6] [Table 1] are placed into subcutaneous tissue to eliminate dead space and into the dermis to minimize tension during wound healing. [4] Absorbable sutures must be placed well into dermis and subcutaneous tissue to facilitate this subsequent absorption by inflammation, enzymatic degradation or hydrolysis. If absorbable sutures are placed too superficially, they may persist for a prolonged period of time and thus possess an increased tendency to be transepidermally eliminated from the wound. This can compromise the appearance of the scar. Absorbable sutures are not intended to be used too close to the skin surface. This slows absorption and increases the likelihood of epithelization of the suture tunnels. This epithelization can result in permanent suture tracts and cyst formation. Surgical gut These sutures are derived from naturally occurring CLASSIFICATION OF SUTURE MATERIALS CLASSIFICATION OF SUTURE MATERIALS

Objective-To describe the macroscopic features of first and second intention cutaneous wound healing in the cat and compare with the dog. Study Design-Experimental study. Animals-Domestic shorthaired cats (6) and beagle dogs (6).... more

Objective-To describe the macroscopic features of first and second intention cutaneous wound healing in the cat and compare with the dog. Study Design-Experimental study. Animals-Domestic shorthaired cats (6) and beagle dogs (6). Methods-Square, open cutaneous wounds created on the dorsal aspect of the thorax were evaluated for 21 days for temporal and spatial development of granulation tissue, wound contraction, epithelialization, and total healing. To evaluate first intention healing, breaking strength of sutured linear cutaneous wounds was measured at 7 days post-wounding. Laser-Doppler perfusion imaging was used to measure cutaneous perfusion. Results-First intention healing: sutured wounds in cats were only half as strong as those in dogs at day 7 (0.406 versus 0.818 kg breaking strength). Second intention healing: cats produced significantly less granulation tissue than dogs, with a peripheral, rather than central distribution. Wound epithelialization and total wound healing (total reduction in open wound area from contraction and epithelialization) were greater for dogs than for cats over 21 days. Wound contraction on day 7 was greater for dogs, but not on day 14 or 21. Cutaneous perfusion was initially greater for dogs than for cats, but no differences were detected after day 7. Conclusions-Significant, previously unreported differences in cutaneous wound healing exist between cats and dogs. In general, cutaneous wounds in cats are slower to heal. Cats and dogs also appear to use different mechanisms of second intention healing. In cats wounds close mainly by contraction of the wound edges, whereas in dogs wounds close more from central pull, and epithelialization. Clinical Relevance-Surgeons should view the cat as a unique species, which presents its own special challenges in wound healing, and should take this into account when planning treatment of feline wounds, either by primary closure, or by second intention healing.

Background Hematoma is the most common postoperative complication of rhytidoplasty, resulting in higher morbidity and longer recovery. Quilting suture for closure of the undermined area in abdominoplasty avoids the occurrence of seroma.... more

Background Hematoma is the most common postoperative complication of rhytidoplasty, resulting in higher morbidity and longer recovery. Quilting suture for closure of the undermined area in abdominoplasty avoids the occurrence of seroma. Based on this principle and with the objective of reducing the number of patients with hematomas in rhytidoplasty, a similar surgical tactic was developed in which a hemostatic net is created with a running transfixing suture of 5-0 nylon encompassing the skin and the superficial musculoaponeurotic systemplatysma. Methods The study enrolled 525 consecutive patients who underwent rhytidoplasty between July 2009 and February 2013. The first 120 patients (group A) were evaluated retrospectively and considered control subjects. The remaining 405 patients (group B) had application of the described tactic, with data collected prospectively. The occurrence of hematoma, ischemia, and necrosis was observed during the first 72 h after surgery. Results Control group A included 17 patients with hematoma (14.2 %) during the first 72 h, whereas no patient in group B experienced such a complication (p \ 0.001). The surgical tactic did not significantly increase the occurrence of ischemia. This complication was experienced by 11 patients in group A (9.2 %) and 26 patients in group B (6.4 %) (p = 0.408). The tactic also did not change the incidence of necrosis, which was present in three group A patients (2.5 %) and six group B patients (1.5 %) (p = 0.723). Conclusion The hemostatic net is an efficient and safe method for preventing early hematomas in rhytidoplasties.

Torn earlobes are a common problem in women wearing heavy earrings (Figure 1A and B). Torn earlobes result from different forms of trauma, in-cluding pulling of the earring by babies; spousal abuse; having the earring caught in telephone... more

Torn earlobes are a common problem in women wearing heavy earrings (Figure 1A and B). Torn earlobes result from different forms of trauma, in-cluding pulling of the earring by babies; spousal abuse; having the earring caught in telephone cords, hairbrushes, and clothing; or simply ...

The aim of this study was to compare the outcome and complications of sutureless trabeculectomy with conventional trabeculectomy. A total of 52 eyes were randomly assigned to two groups. One group received standard conventional... more

The aim of this study was to compare the outcome and complications of sutureless trabeculectomy with conventional trabeculectomy. A total of 52 eyes were randomly assigned to two groups. One group received standard conventional trabeculectomy and the other group received sutureless trabeculectomy. The patients were evaluated at 1, 3, 6 and 12 months after surgery. Patient data such as sex, age, intraocular pressure (IOP), logMAR visual acuity, antiglaucoma medications, and intraoperative and postoperative complications were collected and statistically analyzed. The mean age of the conventional and sutureless groups was 48.5 ± 15.4 and 57.3 ± 13.9 years, respectively. All patients achieved IOP levels \21 mmHg with a mean IOP of 13.4 ± 5.3 mmHg in the conventional group and 12.8 ± 2.6 mmHg in the sutureless group at 6 months and 11.00 ± 1.3 and 12.4 ± 3.2 mmHg at 12 months post surgery, respectively. These results showed a significant decrease compared to preoperative measures but did not show a significant difference between the two groups (p = 0.659). The number of antigalucoma medications used postoperatively showed a significant decline from preoperative status of 0.7 ± 0.58 in the conventional group and 0.4 ± 0.4 in the sutureless trabeculectomy group after 6 months and 0.68 ± 0.8 and 0.78 ± 0.9 after 12 months, respectively; however, there was no significant difference between the two groups (p = 0.112). No intraoperative complications were encountered in any of the groups. One patient in the sutureless trabeculectomy group developed mild hyphema which was managed medically. In the conventional group, two patients had failed trabeculectomy which was successfully revised, two patients showed hypotony 2 days after surgery which was managed medically and normal pressure was achieved within 5 days. Sutureless trabeculectomy appears to be a safe and easy method with results comparable to conventional trabeculectomy.

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Background. Hypospadias is a congenital deformity characterised by an abnormally located urethral opening, that could occur anywhere proximal to its normal location on the ventral surface of glans penis to the perineum. Many operations... more

Background. Hypospadias is a congenital deformity characterised by an abnormally located urethral opening, that could occur anywhere proximal to its normal location on the ventral surface of glans penis to the perineum. Many operations had been described for the management of this deformity. Methods. One hundred and fifteen patients with hypospadias were treated at the

New materials (restorative and adhesive) for the treatment of cervical abrasions have produced better results in terms of esthetics (choice and stability of colors) and duration (marginal fit and wear resistance). Nevertheless,... more

New materials (restorative and adhesive) for the treatment of cervical abrasions have produced better results in terms of esthetics (choice and stability of colors) and duration (marginal fit and wear resistance). Nevertheless, conservative restoration of cervical abrasion cannot be considered the most suitable treatment in certain clinical situations: (1) when the abrasion defect involves the root surface, either exclusively or primarily; (2) when a site has difficult esthetic demands resulting from excessive tooth length with gingival recession; and (3) in the presence of root caries. The aim of this case report is to describe the application of the bilaminar technique to treat a deep cervical abrasion associated with a recession-type defect. The bilaminar surgical approach shown here consisted of a connective tissue graft covered by a coronally advanced pedicle flap. The connective tissue graft was placed inside the root concavity to compensate the abrasion space and to prevent s...

Photochemical tissue bonding (PTB) combines photoactive dyes with visible light to create fluid-tight seals between tissue surfaces without causing collateral thermal damage. The potential of PTB to improve outcomes over standard of care... more

Photochemical tissue bonding (PTB) combines photoactive dyes with visible light to create fluid-tight seals between tissue surfaces without causing collateral thermal damage. The potential of PTB to improve outcomes over standard of care microsurgical reanastomoses of blood vessels in ex vivo and in vivo models was evaluated. The mechanical strength and integrity of PTB and standard microsurgical suture repairs in ex vivo porcine brachial arteries (n = 10) were compared using hydrostatic testing of leak point pressure (LPP). Femoral artery repair in vivo was measured in Sprague-Dawley rats using either standard microvascular sutures (n = 20) or PTB (n = 20). Patency was evaluated at 6 hours (n = 10) and 8 weeks post-repair (n = 10) for each group. PTB produced significantly higher LPPs (1,100+/- 150 mmHg) than suture repair (350+/-40 mmHg, P<0.001) in an ex vivo study. In an in vivo study all femoral arteries in both suture and PTB repair groups were patent at 6 hours post-repair. At 8 weeks post-repair the patency rate was 80% for both groups. No evidence of aneurysm formation was seen in either group and bleeding was absent from the repair site in the PTB-treated vessels, in contrast to the suture repair group. PTB is a feasible microvascular repair technique that results in an immediate, mechanically robust bond with short- and long-term patency rates equal to those for standard suture repair.

A 30-year-old man presents to the office 6 weeks after a softball jammed the right, dominant index finger. He was referred to the hand clinic with a 35°extensor lag of the proximal interphalangeal (PIP) joint (boutonniere deformity) that... more

A 30-year-old man presents to the office 6 weeks after a softball jammed the right, dominant index finger. He was referred to the hand clinic with a 35°extensor lag of the proximal interphalangeal (PIP) joint (boutonniere deformity) that is passively correctable.

Vesicoureteral reflux (VUR) is the most common uropathy affecting children. Compared to children without VUR, those with VUR have a higher rate of pyelonephritis and renal scarring following urinary tract infection (UTI). Options for... more

Vesicoureteral reflux (VUR) is the most common uropathy affecting children. Compared to children without VUR, those with VUR have a higher rate of pyelonephritis and renal scarring following urinary tract infection (UTI). Options for treatment include observation with or without antibiotic prophylaxis and surgical repair. Surgical intervention may be necessary in patients with persistent reflux, renal scarring, and recurrent or breakthrough febrile UTI. Both open and endoscopic approaches to reflux correction are successful and reduce the occurrence of febrile UTI. Estimated success rates of open and endoscopic reflux correction are 98.1% (95% CI 95.1, 99.1) and 83.0% (95% CI 69.1, 91.4), respectively. Factors that affect the success of endoscopic injection include pre-operative reflux grade and presence of functional or anatomic bladder abnormalities including voiding dysfunction and duplicated collecting systems. Few studies have evaluated the long-term outcomes of endoscopic injection, and with variable results. In patients treated endoscopically, recurrent febrile UTI occurred in 0-21%, new renal damage in 9-12%, and recurrent reflux in 17-47.6% of treated ureters with at least 1 year follow-up. These studies highlight the need for standardized outcome reporting and longer follow-up after endoscopic treatment.

To evaluate the anatomical and functional outcomes of sutureless scleral buckling for the repair of rhegmatogenous retinal detachment (RD). Retrospective interventional case series. Retrospective analysis of 50 eyes of 49 patients with... more

To evaluate the anatomical and functional outcomes of sutureless scleral buckling for the repair of rhegmatogenous retinal detachment (RD). Retrospective interventional case series. Retrospective analysis of 50 eyes of 49 patients with rhegmatogenous RD, who underwent sutureless scleral buckling from January 2009 to March 2013. Primary retinal re-attachment rate of 86% was achieved with single surgery, but final anatomical success was 94% with additional interventions in the form of intravitreal gas, buckle revision, and/or pars plana vitrectomy. Best corrected logarithm of minimum angle of resolution visual acuity improved from 1.44 ± 1.01 preoperatively to 0.50 ± 0.40 at a mean follow-up of 6.7 months.XS Conclusion: Sutureless scleral buckling achieves excellent anatomical and functional success in majority of the patients with rhegmatogenous RD.

This paper reports a continuous horizontal mattress suture technique with advantages such as decreased time for anastomosis, minimized anastomotic leakage, eversion around the vessel edges, and other advantages which the continuous... more

This paper reports a continuous horizontal mattress suture technique with advantages such as decreased time for anastomosis, minimized anastomotic leakage, eversion around the vessel edges, and other advantages which the continuous anastomosis technique has. This ...

Background Incisional hernia is a common complication of abdominal surgery and an important source of morbidity. It may be repaired using open suture, open mesh or laparoscopic mesh techniques. This review examines the results of these... more

Background Incisional hernia is a common complication of abdominal surgery and an important source of morbidity. It may be repaired using open suture, open mesh or laparoscopic mesh techniques. This review examines the results of these methods of repair. Methods A Medline literature search was performed to identify articles relating to ‘incisional hernia’, ‘ventral hernia’ and ‘wound failure’. Relevant papers from the reference lists of these articles were also sought. Results The recurrence rate after open suture repair may be as high as 31–49 per cent; for open mesh repair it is between 0 and 10 per cent. Comparative studies show that recurrence is significantly more frequent after open suture repair than after open mesh repair; complication rates are similar for both procedures. Recurrence rates after laparoscopic mesh repair vary from 0 to 9 per cent. Comparative studies show that laparoscopic mesh repair is at least as safe and effective as open mesh repair. Conclusion Open sut...

Background. Although robotically assisted coronary arterial anastomoses are being performed clinically, the short-term and long-term quality and integrity of the left internal thoracic artery (LITA) to left anterior descending artery... more

Background. Although robotically assisted coronary arterial anastomoses are being performed clinically, the short-term and long-term quality and integrity of the left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis remains unknown. The goal of ...

A subtotal colectomy was performed on 12 normal adult cats using an interrupted apposing suture pattern of monofilament polyglyconate (n = 6) or a biofragmentable intestinal anastomosis ring (Valtrac, Davis and Geck Company, Danbury. CT)... more

A subtotal colectomy was performed on 12 normal adult cats using an interrupted apposing suture pattern of monofilament polyglyconate (n = 6) or a biofragmentable intestinal anastomosis ring (Valtrac, Davis and Geck Company, Danbury. CT) (n = 6) composed of polyglycolic acid and barium sulfate. Abdominal radiographs were made daily, beginning 10 days after surgery, to determine fragmentation rates of the anastomosis ring. The cats were euthanatized 30 days after surgery, and a gross and histopathological evaluation of anastomotic healing and stricture formation was performed. The technique for implantation of the anastomosis ring was easy to learn and required only two purse string sutures to complete. Intraoperative complications associated with the anastomosis ring were minor, and included problems with purse string suture placement, small serosal tears, and spasms of the colon that reduced the lumenal diameter. There were no intraoperative complications in the cats with sutured anastomoses. Postoperative recovery was uneventful in all cats. The anastomosis rings fragmented 12.2 k 1.1 days (mean ? standard deviation [SD]) after implantation and passed in the stool 3.8 k I .9 days later without clinical signs in five of six cats. There were no statistically significant differences between the time required to perform the anastomosis (P = .348), postmortem gross anastomosis grades (P = .OM), or percent of lumenal stricture (P = .178) between the two groups. Histologically, the only significant differences were an increased muscular inversion in the anastomoses performed using the fragmentable ring (P = .039) and an increased muscular eversion in the sutured anastomoses (P < ,001) compared with normal colonic architecture. OCopyright I994 bj) The American Collrgr of Veterinurs S~rrgc~ons HRONIC MEGACOLON, in cats, can be C temporarily managed with medical therapy, however, subtotal or total colectomy is a more definitive treatment. A biofragmentable anastomosis ring (BAR)(Davis and Geck Company, Danbury, CT) has several properties that make it promising for application in the surgical treatment of feline megacolon. Anastomoses using the BAR are relatively simple to perform and result in consistently successful small intestinal anastomoses in dogs, swine, and humans.'.' There is minimal fecal contamination during implantation and leakage from the anastomotic site is u n u~u a l .~.~-~ In addition, there is no permanent foreign material left at the anasto-From the

BACKGROUND Rectal prolapse (RP) is one of the benign anorectal diseases and impairs the quality of life due to co-existing constipation and incontinence problems. There is no consensus for the most accurate surgical method for its... more

BACKGROUND Rectal prolapse (RP) is one of the benign anorectal diseases and impairs the quality of life due to co-existing constipation and incontinence problems. There is no consensus for the most accurate surgical method for its treatment. AIM The objective was to evaluate the short- and long-term results of patients with rectal prolapse who underwent surgery in our clinic. MATERIAL AND METHOD A retrospective analysis was performed of 83 patients with RP who underwent surgery between 1997-2013 in terms of demographic data, surgical technique, complications, and early and late outcomes. RESULTS The mean age was 45 years (± 18 years) and 60% (n = 50) of the patients were female. The mean body mass index (BMI) was 24.3 (± 4.1) kg/m2. The mean age was significantly higher in the transperineal approach (PA group) than transabdominal approach (TA group) (p < 0.05). The length of hospital stay was not affected by surgical technique (open or laparoscopic or perineal surgery), but in th...

Background: Several advances in robotic technology and imaging systems have enabled the broad application of minimally invasive techniques in cardiac surgery. We have previously demonstrated that real-time three-dimensional... more

Background: Several advances in robotic technology and imaging systems have enabled the broad application of minimally invasive techniques in cardiac surgery. We have previously demonstrated that real-time three-dimensional echocardiography (RT3DE) provided adequate imaging and anatomic detail to act as a sole guide for surgical task performance. In this study, we examined the feasibility of robotic-assisted RT3DE-guided repair of atrial septal defect (ASD) in an in vitro study. Materials and methods: Exp. I: An RT3DE system with x4 matrix transducer (Sonos 7500, Philips Medical Systems, Andover, MA) was compared to two-dimensional echo (2DE) in the performance of common surgical tasks with the da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA). Completion times and deviation of suture from an echogenic target (mm) were measured. Exp. II: Porcine ASDs (n = 10) were created and closed with robotic-assisted direct suturing in a water bath. During all experiments the operator was blinded to the target and operated only under ultrasonic guidance. Results: Compared to 2DE guidance, completion times improved by 70% (p < 0.0001) and deviation of suture by the robotic system was significantly smaller (2DE: 4 AE 2 mm, 3DE: 0.2 AE 0.3 mm, p = 0.0002) in RT3DE-guided tasks. RT3DE provided satisfactory images and sufficient anatomical detail for suturing. All surgical tasks were successfully performed with accuracy. Conclusions: These initial experiments demonstrate the feasibility of robotic-assisted direct closure of ASD under RT3DE guidance. An endoscopic port access approach may be possible with refinements in telemanipulator technology and further development of the transesophageal echo transducer.

The purpose of this study was to determine the outcomes among three different surgical approaches for performing an aortopexy to treat severe tracheomalacia (STM). Methods: A retrospective review was performed for all patients who... more

The purpose of this study was to determine the outcomes among three different surgical approaches for performing an aortopexy to treat severe tracheomalacia (STM). Methods: A retrospective review was performed for all patients who underwent an aortopexy by pediatric surgeons at a single institution during 1997-2012. Data collected included details of the operative approaches and clinical results. The data were analyzed using Chi-square and Fisher exact test. Results: Forty-one patients underwent an aortopexy. The operation was chosen by the surgeon and not randomized. Exposure was by partial sternotomy (PS) (20), open thoracotomy (12), or thoracoscopic approach (7). Only the PS approach was done by a single team. All groups showed improvement in work of breathing, prevention of severe respiratory distress, and acute life threatening events. These effects were more dramatic for the PS group, especially regarding oxygen and/or ventilator dependence and the ability to undergo tracheostomy decannulation. Among the sixteen patients with failure-to-thrive before successful aortopexy by any technique, ten demonstrated significant improvement in their growth (p = 0.025). The recurrence rate for the thoracoscopic approach was 38%, and there were no recurrences in the partial sternotomy and the thoracotomy groups, 38% vs 0% vs 0%, p = 0.005. Simultaneous bronchoscopy was utilized more commonly in the PS group compared to the thoracotomy and thoracoscopic group, 95% vs 62% vs 38%. Conclusions: In this series, the partial sternotomy technique had the most reliable resolution of symptoms and no recurrence requiring reoperation. The PS approach to STM has the technical advantages of an improved exposure with equal access to the vessels over the right and left mainstem bronchi, as well as the trachea and a more specific elevation of the arteries, including suspension of the pulmonary arteries and trachea itself when desirable. Simultaneous bronchoscopy during aortopexy and an experienced team also likely contribute to improved outcomes. The variations in populations, follow-up, and use of continuous intraoperative bronchoscopy, however, make firm conclusions difficult.

Endovascular aneurysm repair (EVAR) has transformed therapy for aortic aneurysms and introduced an era of widespread use for endovascular procedures in a variety of vascular beds. While dramatic improvements in acute outcomes drove the... more

Endovascular aneurysm repair (EVAR) has transformed therapy for aortic aneurysms and introduced an era of widespread use for endovascular procedures in a variety of vascular beds. While dramatic improvements in acute outcomes drove the early enthusiasm for EVAR, a realization that the integrity of the endoprostheses used for EVAR was significantly inferior to results obtained with open surgical reconstruction dampened enthusiasm for their use in low-risk patients and mandated long-term follow-up for EVAR patients. The future of EVAR as a primary approach to aortic aneurysm repair rests on development of technologies and techniques that can reproduce the foundations and, therefore, the results of open surgical reconstruction. Many of these technologies will be used initially to address the failing endoprostheses, but will have a larger role in their application as a primary component of EVAR.

Postpartum haemorrhage (PPH) occurs in 5% of all deliveries and is responsible for a major part of maternal mortality. Adequate attendance to this complication can mean the difference between life and death. A well-trained staff together... more

Postpartum haemorrhage (PPH) occurs in 5% of all deliveries and is responsible for a major part of maternal mortality. Adequate attendance to this complication can mean the difference between life and death. A well-trained staff together with clear and simple guidelines can make a significant difference to the patient. The aim of this article is to offer a practical guide for the management of PPH; a flowchart is presented. When faced with refractory hemorrhage, one can switch to interventional therapy or surgery. Efficiency and speed play a key part in the approach to this life threatening bleeding.

ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com INDICATIONS The indication for transureteroureterostomy is to bypass a distal ureter without compromising the recipient ureter with disease from the donor renal unit. It is... more

ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com INDICATIONS The indication for transureteroureterostomy is to bypass a distal ureter without compromising the recipient ureter with disease from the donor renal unit. It is useful in patients who have had previous pelvic surgery that would make a ureteroneocystostomy with a psoas hitch, with or without a bladder flap procedure, difficult or inadvisable. The procedure is not recommended under the following circumstances: chronic pyelonephritis, renal calculus disease, previous ureteric trauma with scar, idiopathic retroperitoneal fibrosis, fibrosis following previous aortoiliac vascular surgery, high-dose radiation therapy, urosepsis, uroepithelial tumours, pelvic visceral tumours with ureteric involvement, or inadequate ureteric length for a tension-free anastomosis. The procedure is useful when the better of the two ureters is reimplanted into the bladder. When a normal ureter remains after nephrectomy, a transureteroureterostomy will provide drainage for the remaining kidney when its ureter is diseased. The procedure is of value when the smaller of two ureters is anastomosed to the larger one, which is then used to bridge the abdominal wall and form a stoma.

Background/purpose: In neonatal surgery, preserving small bowel length is important to avoid short bowel syndrome. Our aim was to assess the outcomes of intraluminal stenting of neonatal multiple intestinal anastomoses. Methods: We... more

Background/purpose: In neonatal surgery, preserving small bowel length is important to avoid short bowel syndrome. Our aim was to assess the outcomes of intraluminal stenting of neonatal multiple intestinal anastomoses. Methods: We conducted a retrospective review of 9 patients (5, single institution; 4, published literature) who received multiple anastomoses stented by a silicon tube. Demographics, surgical anatomy and complications, nutritional outcomes, and follow-up were reviewed. Results: Diagnosis was multiple intestinal atresias in 8 patients and necrotizing enterocolitis in 1. A silicon catheter entered either the mucous fistula (5 patients received a jejunostomy/mucous fistula) or a proximal opening on the dilated bowel and was threaded through viable segments of the bowel. The bowel ends were approximated. Stent was externalized in 7 patients. Final mean small bowel length was 63.9 cm. All complications (3 patients, leak/stricture) required surgery. Mean time to stent removal, feeds initiation, and parenteral nutrition (PN) discontinuation was 31.2 days, 17.3 days, and 159 days, respectively. Only 1 patient remains on PN (mean follow-up, 25.4 months). Conclusions: Multiple intestinal anastomoses stenting is an excellent technique to avoid short bowel syndrome in the setting of multiple viable segments of gut, such as type IV intestinal atresia or necrotizing enterocolitis. Both our experience and the published literature show no mortality and PN-free survival.

Background. The purpose of this study was to review our experience with recycling of the pulmonary valve in cases of chronic pulmonary insufficiency after a transannular patch procedure as part of a repair of tetralogy of Fallot. Methods.... more

Background. The purpose of this study was to review our experience with recycling of the pulmonary valve in cases of chronic pulmonary insufficiency after a transannular patch procedure as part of a repair of tetralogy of Fallot. Methods. Eight patients in whom the technique was used were reviewed. Technically, the valve was reapproximated at the anterior commissure if the valve leaflet was sufficiently developed and of good tissue quality. Additional corrections were performed in 5 patients (resection of an infundibular aneurysm [5 patients], repair of the tricuspid valve [1 patient]). Results. The valve was competent with no or trivial regurgitation in 5 patients and a small regurgitation in 3 patients. There was no significant transvalvular gradient in 5 patients with tricuspid valves and a small gradient in 3 patients with a bicuspid valves (< 23 mm Hg). The valve function remained stable over the follow-up period (median time, 32 months). Conclusions. Recycling of the pulmonary valve is an interesting concept that could avoid the necessary reoperations linked with valves or valved prostheses. The repair must be carefully followed in bicuspid valves because of a reduction in the opening area. Valve leaflets of good quality should be preserved during the primary repair of tetralogy of Fallot and the transannular incision should be made across the anterior commissure if possible. These steps should allow a few patients to profit from a recycling of their valves in the future.

The authors have indicated no significant interest with commercial supporters. M edian lip fissures are rare benign lesions of the lower lip with a prevalence in the general population of six in 1,000. This condition affects the upper and... more

The authors have indicated no significant interest with commercial supporters. M edian lip fissures are rare benign lesions of the lower lip with a prevalence in the general population of six in 1,000. This condition affects the upper and lower lips but the lower lip more so. These fissures are four times as common in men 1,2 and cause soreness and episodes of spontaneous bleeding. 2 There is no direct correlation between smoking and lip fissure development. 1 In our present report, we present four cases of inferior lip fissure treated using excision and Z-plasty.