The radial forearm flap

Described in 1981 by the Chinese authors Yang Kuofan et al. [1] as a free flap, then in 1982 by Lu et al. [2] as a retrograde flow pedicle flap, this fasciocutaneous flap is designed at the level of the anterior and external faces of the forearm, and vascularized by the radial artery via a network of septal arteries. Prior to utilization it must be reversed on its distal pedicle. This flap allows repairing cutaneous substance loss of the whole hand and fingers. The emergence of the Chinese flap in the 1980’s resulted in a regression of the Mac Gregor groin flap that was widely used at this time [3,4]. Nevertheless, other forearm flaps, less “expensive” in terms of vascular involvement [5–9] have reduced its indications. The Chinese flap however keeps two essential indications: the multi-finger important defect that no other forearmflapmay cover; and composite substance loss of the thumb (despite the fact that the Chinese flap shares these indications with interosseous artery composite flaps).     

Use of pedicled greater omental flap to repair a thoraco-abdominal defect after extensive tumor resection

Resection of longstanding chest or abdominal wall malignancies can create extensive defects. Pedicled or free myocutaneous flaps [3–6, 8, 9, 12, 14–17] are often the choice for reconstruction. The omental flap, however, is a valid alternative [1, 2, 8, 19, 22]. A case is reported in which the omental flap was used to cover the defect resulting from the resection of an extensive basal cell carcinoma of the lateral thorax and abdominal wall. Fibrosis and calcification of the omentum lead to a stable abdominal wall without the use of synthetic mesh [20, 23]. Received: 3 January 2000 / Accepted: 10 July 2000     

指背旗形皮瓣的实验研究与临床应用

为探讨指背旗形皮瓣的成活机理，应用恒河猴１只，做了８个指背旗形皮瓣的实验，其中近端蒂６个，远端蒂２个，术后作系统的肉眼摄像，激光多普勒血流测定和组织人段叶片观察，结果显示：（１）当皮瓣的长：宽为１０：１时，仍能成活，且无发紫，水肿出现。（２）术后前２天皮瓣的激光多普勒测定值较术前水平稍有下降，但不明显（Ｐ〉０．０５）。术后第３天开始，血流测定值逐渐上升，于第５天达到或超过术前水平；（３）皮瓣成活后     

Posterior urethral reconstruction

Summary The posterior prostatomembranous urethral stricture or distraction defect has historically been the most formidable challenge of stricture surgery. This uncommon lesion occurs most often as the sequelae of pelvic fracture injuries, or straddle trauma, and is associated with serious urethral disruption and separation – an injury that is often complicted by inappropriate initial management using substitution skin flap techniques with the development of recurrent stenosis, irreversible impotence, and occasional incontinence. Management by endoscopic techniques may be possible in patients with short strictures or in those after prostatectomy, but they rarely play a role in resolving the complex obliterated urethra with a significant defect [1]. Resolution of post-traumatic posterior urethral distraction defects and other posterior urethral pathologic conditions has dramatically improved over the past two decades despite an inaccessible subpublic location involving exposed sphincter-active and erectile neurovascular anatomy. The contemporary, perineal, one-stage bulboprostatic anastomotic operation as popularized by Turner-Warwick [20] with selective scar excision is a versatile procedure with a high patent lumen success. Patients undergoing anastomotic urethroplasty have a substained patent urethral lumen success rate approaching 100 % versus those who have undergone urethral skin flap or patch repair, where the restricture rate in 5 and 10 years increases twofold to threefold [1, 20]. A patent urethra after an anastomotic urethroplasty at 6 months is free from further recurrent stricture and gives credence to Mr. Turner-Warwick's admonition that “urethra is the best substitute for urethra”.      

Vascular cognitive impairment

Opinion statement Although vascular dementia remains the only form of dementia that is preventable, available treatment is limited to the primary and secondary prevention of cerebrovascular disease. Strokes are highly responsive to different forms of prevention and treatment. The effectiveness of the same measures in the prevention of vascular dementia remains unclear, however, owing mainly to the lack of agreement on the definition and management of cognitive impairment. The successful treatment of “vascular dementia” involves the recognition of this term as obsolete, for it falsely implies that the underlying cognitive impairment has an unknown degenerative cause, is progressive, and responds neither to currently available preventive measures nor to treatments [1], Class III]. Although dementia resulting from multiple strokes can be a terminal manifestation of this form of cognitive impairment, most patients have treatable cerebrovascular disease. A rational therapeutic approach to the treatment of this cognitive syndrome necessitates an understanding of its broad clinical spectrum and the diverse causes that may be responsive to currently available treatments, from the clinical asymptomatic “brain-at-risk” stage to full-blown dementia [2], Class III].     

Per-oral dual scope NOTES cholecystectomy in porcine model (with video)

Background  

Several working groups have already demonstrated the feasibility of transgastric surgery procedures using flexible endoscopes. However, technical limitations in natural orifice translumenal endoscopic surgery (NOTES) (e.g., exposure, retraction, insufflations, and triangulation) currently still require the use of at least one external instrument [1–3]. Therefore, “pure NOTES” transgastric cholecystectomy has not yet been described. The authors successfully performed “pure NOTES” transgastric cholecystectomy using a transoral dual-scope technique (similar to the approach the authors previously reported for gastric closure [4]) that allows completion of the procedure by pure NOTES without an external instrument.     

Use of lotus petal flap in the treatment of perineal hidradenitis suppurativa

Perineal hidradenitis suppurativa is a complex problem to treat. Various methods of treatment have been tried in the past, but recurrence was common. In this paper, we describe the use of the lotus petal flap in hidradenitis suppurativa of the perineum in three patients. Many local flaps have been used for covering the defect after excision of hidradenitis suppurativa; in our cases, we have used the lotus petal flap. Until now, this flap has been used for vaginal reconstruction after cancer surgery [Yii NW, Niranjan NS (1996) Lotus petal flaps in vulvo vaginal reconstruction. Br J Plast Surg 49(8):547–554, Hashimoto I et al (1999) Vulvo vaginal reconstruction with gluteal fold flaps. J Jpn P R S 19:92–98]. Three patients had five lotus petal flaps after the excision of perineal hidradenitis suppurativa, and there were no recurrences of the lesion in the excised area after follow-up at 2 years.     

Evaluation of a new virtual-reality training simulator for hysteroscopy

Background  To determine realism and training capacity of HystSim, a new virtual-reality simulator for the training of hysteroscopic interventions. Methods  Sixty-two gynaecological surgeons with various levels of expertise were interviewed at the 13^th Practical Course in Gynaecologic Endoscopy in Davos, Switzerland. All participants received a 20-min hands-on training on the simulator and filled out a four-page questionnaire. Twenty-three questions with respect to the realism of the simulation and the training capacity were answered on a seven-point Likert scale along with 11 agree–disagree statements concerning the HystSim training in general. Results  Twenty-six participants had performed more than 50 hysteroscopies (“experts”) and 36 equal to or fewer than 50 (“novices”). Four of 60 (6.6%) responding participants judged the overall impression as “7 – absolutely realistic”, 40 (66.6%) as “6 – realistic”, and 16 (26.6%) as “5 – somewhat realistic”. Novices (6.48; 95% confidence interval [CI] 6.28–6.7) rated the overall training capacity significantly higher than experts (6.08; 95% CI 5.85–6.3), however, high-grade acceptance was found in both groups. In response to the statements, 95.2% believe that HystSim allows procedural training of diagnostic and therapeutic hysteroscopy, and 85.5% suggest that HystSim training should be offered to all novices before performing surgery on real patients. Conclusion  Face validity has been established for a new hysteroscopic surgery simulator. Potential trainees and trainers assess it to be a realistic and useful tool for the training of hysteroscopy. Further systematic validation studies are needed to clarify how this system can be optimally integrated into the gynaecological curriculum.     

“Secondary stacking” as a shaping option in former breast augmentation with polyurethane coated implants

“Stacking”– the insertion of several polyurethane (PU) coated prostheses in breast augmentation as propagated by Hester et al. [3] – often proves to be an interesting option in problem situations in cosmetic breast surgery. Caution is advised, however, in correcting augmentation surgery. The original PU-coated implant should not be removed since this can cause complications. All further implants should be placed in a “virgin” submuscular pocket. Received: 23 June 1997 / Accepted: 13 January 1998     

Die Implantation anatomisch adaptierter Hüftgelenksendoprothesen mit Stufenosteotomie des proximalen Femurendes vom anterolateralen Zugang aus

Operationsprinzip Anatomisch adaptierte Stiele von Hüftendoprothesen passen zentrisch in die Markh?hle des Femur und berücksichtigen seine S-f?rmige—proximal dorsalkonvexe, weiter distal ventralkonvexe—Krümmung [5]. Drehfehler werden vermieden. Bei der Stufenosteotomie schneidet der Endoprothesenkragen die mittlere Druckresultierende des Schenkelhalses senkrecht und lagert sich U-f?rmig der Resektionsfl?che des Schenkelhalses auf [2] (Abbildung 1 und Abbildung 13). Zementfrei zu implantierende Endoprothesenstiele besitzen eine “metallspongi?se” Oberfl?che, die Pfannenimplantate eine “metallspongi?se” Stützpfanne und ein Poly?thyleninlay [3].      

A reliable method for handling the “difficult” cystic duct to obtain a good cholangiogram during laparoscopic cholecystectomy

Background Intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) is used to assess the anatomy of the biliary tree and to detect any stones contained within it. Intraoperative cholangiography may be performed either routinely or more selectively in cases where there is a high suspicion of choledocholithiasis or for those patients whose anatomy appears unclear at operation [8]. In cases where significant inflammation is present, the cystic duct may be short, thickened, or dilated and thus difficult to manipulate to obtain a satisfactory IOC. Methods We describe a safe, simple, reliable technique to control the “difficult” cystic duct during IOC with a vascular vessel loop instead of a surgical clip to obtain good control and avoiding extravasation of dye during IOC. The feasibility, safety, and results of this technique are described. Results During a 1-year period, this technique has been used in 10 patients, and it was successful in all attempted cases, with a good quality IOC obtained on the first attempt. The cystic duct was then occluded in all cases using a Vicryl “0” endoloop. One patient had a common bile duct stone and this patient received postoperative endoscopic retrograde pancreatography (ERCP). All patients were discharged home with no complications. In cases where a short, thickened, or dilated cystic duct was present, ductal control during IOC was easily obtained using a vascular vessel loop. Conclusions This is a safe, reliable, less traumatic, readily available, and inexpensive method that provides a secure way of handling the “difficult” cystic duct.     

Changes in the education of a vascular surgeon

Conclusion Education of the vascular surgeon has changed as the field itself has developed. Training now exists where there was none. Essentials of such training have been set and educational programs have developed to encompass those essentials. As this has occurred, vascular surgical training has bettered general surgical education and has not detracted from it. In the words of Goethe, “The history of the world must be rewritten from time to time, not because many events of the past are being rediscovered, but because new vistas are opening up, new ways of looking at things which show the past in a different light”. ?This is the function of our own and of every age: to grasp the knowledge which is already existing, to make it our own, and in so doing to develop it still further and to raise it to a higher level”. G.W.F. Hegel. On Philosophy. Presented at “Vascular Surgery: The Thirty Year Reunion”. Meadow Brook Hall, Rochester, Michigan, May 25–26, 1984.     

Limberg flap procedure for pilonidal sinus disease: results of 353 patients

Purpose Pilonidal sinus disease is common especially in young adult males. Many surgical and nonsurgical methods have been described. Some surgical techniques for the treatment still have high recurrence rate. The aim of this study was to evaluate advantages and long term results of Limberg flap surgical technique. Methods From November 2001 to December 2004, 353 patients [335 male, 18 female; average age = 24.65 ± 4.2 (range, 15–53) years] with primary or recurrent pilonidal sinus disease were operated on under spinal anesthesia by rhomboid excision and Limberg flap. Follow-up examinations were made at the end of the 4 weeks and 3, 6, 12, 18, and 24 months after surgery. Results The mean duration of symptoms was 23.28 ± 16.09 (range, 2–140) months. The mean duration of hospital stay was 4.51 ± 2.85 (range, 2–19) days. Thirty nine patients (11%) had recurrent disease. Total wound dehiscence and flap necrosis did not occur in any patient. Recurrences were observed in 11 patients (3.1%) at the end of the follow up period. Conclusion Quick healing time, short hospital stay, early return to daily life, low complication and recurrence rate are the important advantages of the Limberg flap procedure. We think using closed suction drain in Limberg flap operation is not necessary. In the light of this study results, Limberg flap surgical technique may be an ideal operation for pilonidal sinus disease.     

A microvascular peritoneal flap based on the deep circumflex iliac artery

Reconstructive surgery following tumor resection or trauma to the oromandibular areas requires one-stage, reliable, functional, and cosmetic results with a low donor site morbidity. In the past 2 decades free vascularized osteocutaneous flaps using the scapular, radial forearm, fibular, and groin flap have shown their advantages [2]. Only recently has the peritoneum been considered part of a vascularized flap to assure primary healing by mucosal defects [1, 3–5]. To show a constant vascular pattern of the deep circumflex iliac artery (DCIA), 17 dissections on fresh cadavers were performed. The visualization was obtained by blue dye coloration, contrast medium angiography, and intravascular silicone latex injections. The results confirmed that the osteocutaneous part of the composite groin flap is constantly supplied by the main branch and the internal oblique transverse muscle, including peritoneum (approximately 8×10 cm), mainly by the ascending branch of the DCIA.     

Arthroscopic lavage for joint infections

Surgical Principles “The joint itself defends best against infection.” The synovial membrane has a great potential in preventing and controlling infections. The joint should not remain open. A primary synovectomy should be avoided [4]. Repeated arthroscopic irrigation follows these guidelines and has a high success rate in eradicating infection and restoring joint mobility. In addition antibiotics are mandatory. The following recommendations are based on a series of 98 infected joints treated by arthroscopic lavage. Revised Version from: Operat. Orthop. Traumatol. 1 (1989), 196–199 (German Edition).     

Upper extremity resurfacing via an expanded latissimus dorsi musculocutaneus flap for large circumferential defects: the “spiral” reconstruction technique

We present an expanded latissimus dorsi musculocutaneus (LDMC) flap to treat circumferential upper extremity defects via resurfacing and “spiral reconstruction” in 5 patients during a 17-year period. Five patients with different indications for tissue expansion from burns to congenital hairy nevi were operated. The expansion was done in a longitudinal direction, and a rectangular tissue expander (TE) was inserted under the LD muscle to expand the flap in a longitudinal direction thereby forming a “long” flap rather than a “wide” one. After excising the circumferential lesion, the expanded “elongated” flap was wrapped spirally around the extremity to cover the defect; the donor site was closed as usual. The 5 patients we treated via LDMC flaps in a spiral fashion were free of complications, and all were satisfied with the outcome. All the flaps survived and the spiral reconstruction allowed for a tension-free donor site closure and near complete recipient coverage. This technique is indicated for large circumferential extremity skin defects and deformities. Application of expanded LDMC flaps in a spiral fashion can be used by the reconstructive surgeon to resurface large circumferential upper extremity lesions when indicated. The idea of a long and thinned expansion flap must be in a longitudinal direction and we need this long expanded and thin flap to “spiral” it around the extremity to cover a large defect. The “spiral” flap coverage introduced here for large circumferential extremity defects enables the surgeon to cover the defect with simultaneous donor site closure and good results.     

Prediction of Osteoporotic Fractures by Bone Densitometry and COLIA1 Genotyping: A Prospective, Population-Based Study in Men and Women

Osteoporosis is a common disease with a strong genetic component, characterized by reduced bone mineral density and increased fracture risk. Although the genetic basis of osteoporosis is incompletely understood, previous studies have identified a polymorphism affecting an Sp1 binding site in the COLIA1 gene that predicts bone mineral density and osteoporotic fractures in several populations. Here we investigated the role of COLIA1 genotyping and bone densitometry in the prediction of osteoporotic fractures in a prospective, population-based study of men (n= 156) and women (n= 185) who were followed up for a mean (± SEM) of 4.88 ± 0.03 years. There was no significant difference in bone density, rate of bone loss, body weight, height, or years since menopause between the genotype groups but women with the “ss” genotype were significantly older than the other genotype groups (p= 0.03). Thirty-nine individuals sustained 54 fractures during follow-up and these predominantly occurred in women (45 fractures in 30 individuals). Fractures were significantly more common in females who carried the COLIA1“s” allele (p= 0.001), although there was no significant association between COLIA1 genotype and the occurrence of fractures in men. Logistic regression analysis showed that carriage of the COLIA1“s” allele was an independent predictor of fracture in women with an odds ratio (OR) [95% CI] of 2.59 [1.23–5.45], along with spine bone mineral density (OR = 1.57 [1.04–2.37] per Z-score unit) and body weight (OR = 1.05 [1.01–1.10] per kilogram). Moreover, bone densitometry and COLIA1 genotyping interacted significantly to enhance fracture prediction in women (p= 0.01), such that the incidence of fractures was 45 times higher in those with low BMD who carried the “s” allele (24.3 fractures/100 patient-years) compared with those with high BMD who were “SS” homozygotes (0.54 fracture/100 patient-years). We conclude that in our population, COLIA1 genotyping predicts fractures independently of bone mass and interacts with bone densitometry to help identify women who are at high and low risk of sustaining osteoporotic fractures. Received: 16 November 2000 / Accepted: 9 June 2000     

Modeling human calcium tracer kinetics using a minimum of assumptions

Summary A conceptually simple model of human calcium kinetics, based on the Bauer-Carlsson-Linquist (B.C.L.) [1, 2] expression, is presented. The B.C.L. model assumes tracer retention in the body, occurs either in an exchangeable pool or in the skeleton, and the rate of calcium transfer from pool to bone (mineralization) is constant. As a modification, it is demonstrated that the existence of an expanding calcium pool and its rate of expansion may be directly determined from the raw data, without a priori assumptions. If data on whole body retention are unavailable, the concept of dermal tracer loss [3] as the difference between tracer excretion and whole body retention may be used to estimate whole body retention. It has been possible to compare the modified B.C.L. expression with various multicompartmental kinetic models by analyzing raw data supplied by other workers and making comparisons with their published results [4–6]. As methodologies are very different, the two sets of estimates of bone mineralization rate and exchangeable pool size have been ranked within individual groups. In five of six comparisons, the results indicate a rank correlation coefficient with a p-value better than 0.05 occurred. In all cases of data analysis from “normal” subjects, the calcium pool was found to be expanding. The existence of an expanding pool renders the model similar to a previous one [7], but the present one is conceptually and mathematically simpler in achieving equivalent results.     

New workhorse flaps in hand reconstruction

With the passage of time, certain hand surgery procedures are anecdotally dubbed “workhorse” techniques. These are procedures that are extremely reliable and have repeatedly demonstrated good results. However, with time, paradigms undergo shifts, and this is as true for hand surgery as any other field. In this article, we will describe the use of three new “workhorse” flaps that we have found to have reliable results in complex hand reconstruction: the pedicled radial forearm fascia flap for dorsal hand reconstruction, the free anterolateral thigh flap for mangled hand reconstruction, and the medial femoral condyle vascularized bone graft for scaphoid fracture nonunion reconstruction.     

McGregor flap

Since it has been described in the early seventies [1], this flap has become an essential tool in reconstructive surgery, primarily due to the wide cutaneous surface it may replace. Its pediculate form is useful and it may be employed with significant benefit as free flap; it may even provide composite tissues. Also known as McGregor’s flap, groin flap, or iliofemoral flap, this axial pattern flap is based on the superficial iliac circumflex artery.