An S-shaped incision for the insertion of deep brain stimulators

Background

The S-shaped incision is a novel technique we have developed to minimise wound complications for the insertion of bilateral deep brain stimulators.

Methods

An S-shaped incision incorporating both burrholes allows better exposure compared to the traditional bilateral incisions. The burrholes are drilled under each limb of the S and the incision does not run across them, decreasing the risk of infection. The electrodes are subsequently tunneled down the right side and connected to the battery.

Conclusion

The use of the S-shaped incision results in less wound and electrode complications compared to the traditional bilateral linear incisions in our experience.     

One-step tunneling of DBS extensions—a technical note

Background

Infection constitutes a serious adverse event in deep brain stimulation (DBS) surgery, being responsible for difficult therapeutic decisions that may ultimately involve the removal of implanted material. Some cases begin with skin erosion and wound dehiscence of the retroauricular incision, which is one of the most fragile points. Several techniques of rotation flaps and skin reconstruction, as well as prolonged antibiotic regimens, have been proposed as therapeutic options. To prevent the onset of this complication, the authors propose a one-step tunneling technique of DBS extensions, avoiding the opening of the retroauricular space.

Methods

We describe a surgical technique of a one-step tunneling of DBS extensions in 20 patients submitted to subthalamic DBS for Parkinson’s disease, avoiding the opening of the retroauricular space.

Results

After implantation of the extensions using this technique, we had no erosions of the retroauricular skin, with a consequent reduction in the number of infections.

Conclusions

The authors describe an easy surgical technique that allows reduction of wound and erosion complications, with great benefits for DBS patients.     

Single-incision multiport laparoendoscopic (SIMPLE) surgery: early evaluation of SIMPLE cholecystectomy in a community setting

Background

Conventional Laparoscopic Cholecystectomy (LC) is a safe, established procedure for gallbladder disease. This is usually performed through three to four small incisions. Although postoperative pain is minimal, there still exists some discomfort from multiple incisions. In theory, fewer incisions or incisionless surgery may decrease postoperative morbidity more than that already exists. Reports of microport instrumentation as well as normal orifice translumenal endosurgery (NOTES) cholecystectomy transvaginally, transcolonically, or transgastrically have recently surfaced. However, these require a different skill set and new technology, which is still in its developmental infancy. Single incision surgery has recently entered the minimally invasive arena.

Methods

Ten consecutive patients requiring laparoscopic cholecystectomy were performed with a single incision multiport technique as described below.

Results

All ten patients had a successful completion of a single incision multiport laparoendoscopic cholecystectomy without need for conversion to two, three, or four incisions. There were no complications and the recovery was comparable to a conventional LC.

Conclusion

We describe here a single incision multiport laparoendoscopic cholecystectomy (SIMPLE cholecystectomy) technique that is safe for the patient, reproducible, easy to learn, and uses commonly available instruments already in most operating rooms. Conversion, if required, is placement of the remaining two to three ports for a more conventional LC.     

Key factors in reducing morbidity following inguinal node dissections

Background

Inguinal node dissection is associated with high incidence of post-operative morbidity.

Methods

We conducted a retrospective review of all patients who underwent inguinal node dissection at The Christie Hospital between 2001 and 2008. Two hundred thirty two patients undergoing 247 inguinal node dissection outcomes were assessed with a median follow-up of 29 months (range 5 to 75).

Results

Our overall complication rate was 61 %. Our wound infection rate is 34 % with 10 % wound necrosis, 25 % wound breakdown, 35 % seroma, 23 % lymphoedema and 0.4 % haematoma rate. The overall and individual complication rate, including infection wound breakdown, skin necrosis, seroma formation and lymphoedema, was significantly lower with use of a transverse incision for access compared to using a Lazy S and longitudinal incisions (P?<?0.008 and P?<?0.0001, respectively). Patients undergoing Sartorius switch had a reduced rate of seroma formation (P?=?0.018). The preservation of the long saphenous veins was also associated with a reduction on the overall complication rate (P?=?0.007).

Conclusions

Inguinal node dissection postoperative complications are reduced by transverse incision, Sartorius switch and preservation of the long saphenous vein. Level of Evidence: Level IV, prognostic/risk study.     

Diaphragmatic relaxing incisions during laparoscopic paraesophageal hernia repair

Background

Laparoscopic paraesophageal hernia (PEH) repair is associated with an objective recurrence rate exceeding 50 % at 5 years. Minimizing tension is a critical factor in preventing hernia recurrence. This study aimed to evaluate the outcomes of crural relaxing incisions in patients undergoing PEH repair.

Methods

Records were reviewed to identify patients who received a relaxing incision during laparoscopic PEH repair. The patients were followed by chest X-ray and videoesophagram at 3 months and then annually.

Results

From November 2010 to March 2013, 58 patients underwent PEH repair, and 15 patients received a relaxing incision to accomplish crural closure. The median age of the patients was 72 years (range 58–84 years). The relaxing incision was right-sided in 13 patients, left-sided in one patient, and bilateral in one patient. All the procedures were completed laparoscopically and included a fundoplication. Collis gastroplasty for a short esophagus was performed for 40 % of the patients. No major complications occurred. During a median follow-up period of 4 months, one patient had an asymptomatic mildly elevated left hemidiaphragm, and one patient had a trivial recurrent hernia, as shown on esophagogastroduodenoscopy (EGD).

Conclusion

Crural tension likely contributes to the high recurrence rate noted with laparoscopic PEH repair. Relaxing incisions are safe and allow crural approximation. Advanced laparoscopic surgeons should be aware of this option when faced with a large hiatus in a patient with PEH.     

A Single-center Large-volume Experience in the Surgical Management of Hydatid Disease of the Lung With and Without Extrapulmonary Involvement

Background

We compared the number of incisions, surgical procedures, hospital duration, and complications in hydatid cyst patients with unilateral or bilateral thoracic involvement and concomitant involvement of the extrathoracic organs.

Methods

A total of 76 hydatid cyst cases surgically treated between the years 2007 and 2012 were divided into three groups according to radiological evidence of other organ involvement and surgical procedures: group 1 had only unilateral thoracic involvement and a single incision; group 2 had additional involvement of the contralateral thoracic side or extrathoracic organs and at most two incisions were performed at the same session; and group 3 had two or more incisions performed at separate sessions in addition to the involvement features of group 2.

Results

We had 46 (60.5 %) cases with only thoracic involvement and 30 others (39.5 %) with extrathoracic organ involvement. Complications were seen in only one patient each in the first and second groups, and in 6 patients in the third group. Duration of hospital stay was 7.04 ± 0.86 (5–9) days in group 1.8.33 ± 1.87 (7–13) days in group 2, and 13.95 ± 2.03 (9–18) days in group 3.

Conclusions

Although multiple session surgery is used to decrease the risk of complications, contamination, and infection in multiple or bilateral pulmonary hydatid cyst cases, or in patients with other organ involvement, single-session surgery can be used in selected cases taking into account the operative trauma, financial consequences, and psychological profile.     

Clinical comparison of four types of skin incisions for skin-sparing mastectomy and immediate breast reconstruction

Purpose

Skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) has become popular as an effective procedure for patients with early breast cancer. We herein report an overview of the four types of skin incisions used for SSM.

Methods

The records of 111 consecutive breast cancer patients, who received SSM and IBR from 2003 to 2012, were reviewed retrospectively. Four types of skin incisions were used. Type A was the so-called tennis racquet incision, type B was a periareolar incision and mid-axillary incision, type C was the so-called areola-sparing with mid-axillary incision and type D was a small transverse elliptical incision and transverse axillary incision.

Results

Twenty-six type A, 59 type B, 20 type C and six type D incisions were made. The average blood loss and average length of the operation during SSM were not significantly different between the four approaches. The average areolar diameter was 35 mm for type A, B and D incisions, and 45 mm for type C. There was a need for postoperative nipple–areolar complex plasty (NAC-P) in 75 % of the cases following type A, B and D incisions, and 35 % of the cases treated using type C incisions.

Conclusion

The type C incision is superior with regard to the cost and cosmetic outcomes, because fewer of these patients request postoperative NAC-P.     

Das akute Kompartmentsyndrom des Unterschenkels

Objective

Decompression of all four muscle compartments of the lower leg to normalize tissue pressure and prevent permanent neuromuscular dysfunction.

Indications

Incipient compartment syndrome (characterized by excessive pain, muscle pain on extension, tensely swollen and shiny skin, and ??p>30?mmHg without neuromuscular deficit) and no clinical improvement after conservative treatment and/or acute compartment syndrome (symptoms as for incipient compartment syndrome with neuromuscular deficit and ??p<30?mmHg).

Contraindications

None. There is some dispute about indications and timing of fasciotomy and necrectomy when the need for dermatofasciotomy is recognized late (e.g. intubated intensive care patients).

Surgical technique

In unilateral compartment release as described by Matsen, the lateral compartment is decompressed first through a parafibular approach. After identification of the anterior and superficial posterior compartments by transverse incision of the fasciae, these muscles are also decompressed longitudinally. Finally, the deep posterior compartment beneath the lateral compartment is decompressed. In bilateral dermatofasciotomy, the fasciae of the anterior and lateral compartments are incised through a proximal anterolateral approach and the superficial and deep posterior compartments through a distal dorsomedial approach.

Postoperative management

Synthetic skin substitute or vacuum-assisted wound closure until definitive closure by secondary suture or mesh grafting after about 5?days. Patient mobilization generally depends on the concomitant bone injury.

Results

During the period from October?2001 to November?2008, 37?dermatofasciotomies were performed at our hospital to treat acute posttraumatic compartment syndrome. On the day of dismissal, symptoms of neuromuscular dysfunction after acute compartment syndrome had not disappeared completely in 5?patients. One patient received intermittent dialysis for acute kidney failure after crush syndrome. There were perioperative complications in a total of 6?patients: iatrogenic neurotomy (n=1), hematoma requiring revision (n=2), deep wound infection (n=2), and superficial disturbed wound healing (n=1).     

Endoscopic bursectomy for the treatment of septic pre-patellar bursitis: a case series

Introduction

Operative treatment for septic pre-patellar bursitis generally involves open debridement in addition to an extended course of intravenous antibiotics. Skin necrosis and wound breakdown are potential complications of this procedure in addition to scar sensitivity and a prolonged recovery.

Method

We report endoscopic bursectomy for the treatment of septic pre-patellar bursitis in eight patients over a 3-year period. All patients had microbiological confirmation of an infective process. The average age was 36?years (23–68?years). The average hospital stay was 6?days (4–9?days).

Results

No patient had a recurrence or complained of tenderness or hypoaesthesia around their wound. No patient experienced wound complications or skin necrosis. The average return to work time was 18?days (7–22?days).

Conclusion

We conclude that endoscopic bursectomy is a safe and effective treatment for septic pre-patellar bursitis with a shortened hospital stay and a quicker return to work than conventional open debridement.     

Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study

Background

Emergency thoracotomy (ET) is a procedure that provides rapid access to intrathoracic structures for thoracic trauma patients arriving at the hospital in extremis. This study assesses the accessibility of intrathoracic structures provided by six different ET incisions. We hypothesize that the bilateral anterior thoracotomy (“clamshell” incision) provides the most rapid and definitive accessibility to intrathoracic structures.

Methods

Six ET incision types (left anterolateral thoracotomy, right anterolateral thoracotomy, left 2nd intercostal space incision, left 3rd intercostal space incision, median sternotomy, and bilateral anterior thoracotomy) were performed multiple times on eight cadavers. The critical intrathoracic structures were assessed for rapid accessibility and control, and they were characterized as “readily accessible,” “accessible,” and “inaccessible” on anatomic accessibility maps.

Results

Median sternotomy provided better access to intrathoracic structures than left and right anterior thoracotomies. Definitive control of the origin of the left subclavian artery was difficult with left 2nd or 3rd intercostal space incisions. Bilateral anterior thoracotomy, the clamshell incision, was easy to perform and gave superior access to all intrathoracic structures.

Conclusions

In severe thoracic trauma, specific injuries are unknown, even if they can be anticipated. The best incision is therefore one that provides the most rapid and definitive access to all thoracic structures for assessment and control. While the right and left anterolateral incisions may be successfully employed by surgeons with extensive experience in ET, the clamshell incision remains the superior incision choice.

Level of Evidence II

Observational study.     

Use of vacuum-assisted closure in open incisional hernia repair: a novel approach to prevent seroma formation

Introduction

Frequent complications in incisional hernia surgery are re-herniation, wound infection and seroma formation. The use of subatmospheric pressure dressings such as the vacuum-assisted closure (VAC) device has been shown to be an effective way to accelerate healing of various wounds. Here, we describe the application of the VAC device as a postoperative dressing to prevent seroma formation after open incisional hernia repair.

Methods

Three consecutive patients (63, 65 and 60 years of age, respectively) underwent incisional hernia repair. Patient body mass index was 30.9, 26.6 and 29 kg/m², respectively. All hernias were complex with a defect size greater than 10 cm and were repaired using the onlay technique. After suture skin closure the incision was covered with a thin VAC sponge (KCI, San Antonio, TX) that was set at ?125 mm Hg and left in place for 5 days before removal.

Results

An abdominal CT scan performed before discharge from the hospital did not show seroma formation. Physical examination 3 months after surgery was normal with no evidence of seroma (abdominal bulge and/or fluid wave).

Conclusions

This successful preliminary experience in three patients encourages the use of the VAC system in incisional hernia repair, particularly in selected patients with risk factors for seroma formation (e.g., large defects, obesity, patient comorbidities, nutritional status, number of prior abdominal incisions, etc.). Therefore, prevention of seroma formation after incisional hernia repair may be added as a novel application of the VAC device.     

The mini postero-postero-lateral mini incision in total hip arthroplasty

Purpose

Mini invasive incisions in THA and femoral hip prostheses tend to minimise healing and recovery time. We have used a very posterior approach with technical modifications and precise skin landmarks to decrease surgical complexity, and we describe this experience here.

Methods

From 2010 to 2012, 140 patients aged 79 years (range 53–93 years) were operated upon by the same surgeon in a continuous series using the same minimally invasive skin incision and six different types of implants. The incision was very posterior in the hip allowing direct visualisation of the acetabulum in the hip flexion position and visualisation of the femoral shaft extremity in a leg flexion position.

Results

The mean operating time was 100 minutes (range 75–110 min). Estimated blood loss was 385 cc (20–585 cc). Twenty-six patients had blood transfusion. The mean hospital stay was 6.8 days (5–20 days) including the time waiting for a rehabilitation centre. No operative complications related to the technique were recorded. On the postoperative radiograph, the femoral stem was aligned with the femoral axis within 3° in all patients. The mean acetabular angle to the ground plane was 40° (35–48°). No patient had a leg length discrepancy of more than four millimetres. The mean skin incision length was seven centimetres (six to eight centimetres). All patients were seen at the clinic after six weeks and the data were unchanged at this time point.

Conclusion

The method and skin landmarks we describe appear to be a safe way to perform minimally invasive total hip replacement.     

Scars after total ear reconstruction with porous polyethylene: the patients’ perspective

Background

Total ear reconstruction with porous polyethylene implants leads to three typical skin scars: a scalp scar from harvesting the temporoparietal fascia flap as well as a groin scar and a contralateral postauricular scar from harvesting full-thickness skin grafts. This study evaluates the annoyance of these scars from the patients’ perspective.

Methods

Fifteen patients received structured questionnaires covering the aesthetical outcome and daily impairment by the three scar types, as well as validated questionnaires measuring health-related quality of life.

Results

The ear reconstruction had raised the health-related quality of life in 14 patients. The scalp and groin scars were rated “satisfactory,” and the postauricular scar was “good” on an average. In contrast to the postauricular scar, the annoyance by scalp and groin scars was substantial: Half of the patients had sensation disorders on the scalp or groin. The scalp scar impaired a third of the patients wearing a desired hairstyle and the groin scar a third of the patients wearing swimsuits. A fifth of the patients experienced feelings of shame in the public due to the scalp and groin scars.

Conclusions

While not preventing the beneficial effect of ear reconstruction on patients’ health-related quality of life, scalp and groin scars are annoying for a relevant percentage of the patients. Therefore, the temporoparietal fascia flap should be harvested with the smallest incision possible, full-thickness skin grafts from the groin should be harvested as small as possible, and harvesting areas for full-thickness skin grafts other than the groin should be evaluated. Level of Evidence: III.     

Brachial lifting using the balanced triple-vector (BTV) technique with dual opposing flaps

Background

Brachioplasty often involves removing excess skin. Many traditional approaches to this form of surgery are prone to complications and imperfect healing of the incisions. Traditional techniques usually take little or no account of the force vectors that are subsequently applied to the incision after the operation. This contributes towards scarring and other complications.

Method

The proposed technique involves the explicit application of three balanced force vectors that greatly reduce scar-related complications. Although the scar is longer, it is on the medial side of the arm and usually fades away completely over time, with greatly improved aesthetic results. A closely related aspect of this technique is the application of anthropometric techniques in order to plan the operation for best results.

Results

The proposed technique has been applied in practice to 23 patients. There were no long-term complications. Temporary paresthesia was observed in 5 patients and temporary swelling of hands in 2 patients. One case of seroma was also detected. Two patient required surgical scar revision. One patient was unsastified with the final scar quality.

Conclusions

Due to the superficial resection in this technique, no damage to the subcutaneous tissue and lymphatic network occurs, resulting in a more predictable outcome with greatly reduced risk of complications. This technique is particularly good at reducing the scar retraction issues most common when using other single-vector approaches. Level of Evidence: Level IV, therapeutic study.     

Two transverse versus single longitudinal incisions for patella tendon harvest in anterior cruciate ligament reconstruction

Background

The bone–patellar–bone autograft is the most commonly used graft in anterior cruciate ligament (ACL) reconstruction surgery. However, harvesting of the graft is associated with various local complications.

Hypothesis

Harvesting the graft via two transverse incisions rather than one longitudinal incision lowers the risk of injury to the infrapatellar branch of the saphenous nerve.

Study design

Retrospective review of prospectively collected data.

Methods

We compared the results of 38 consecutive patients who underwent arthroscopic ACL reconstruction between 12 and 20 months postoperatively. Group A (n = 16) consisted of patients in whom a single longitudinal incision had been used. Group B (n = 22) consisted of patients in whom harvest had been via two transverse incisions.

Results

The mean area of diminished sensation in Group A was 60.48 cm², range 0–195, and in Group B was 32.19 cm², range 0–132 (P = 0.028, t-test). The width and pigmentation of the scars were significantly less with the two transverse incisions technique. There was no significant difference between the two groups in any other tested parameter.

Conclusions

The use of two transverse incisions was associated with a reduced area of altered sensation and objective evidence of a more cosmetically acceptable scar. We advocate the routine use of the two transverse incisions technique for graft harvest in ACL reconstructive surgery.     

Outcome of transilluminated powered phlebectomy for varicose vein: review of 299 patients (447 limbs)

Purpose

Varicose vein incompetence in the legs is very prevalent in the Korean population. New technologies and improvements in established methods have changed the treatment of varicose veins. Transilluminated powered phlebectomy is an alternative surgical technique that combines endoscopic powered vein resection and ablation of superficial varicosities with tumescent anesthesia and irrigated illumination. The present study sought to determine the clinical efficacy and safety of transilluminated powered phlebectomy from clinical data.

Method

Four hundred and forty-seven limbs in 299 patients (157 male, 142 female; mean age 50.6 years) with varicose veins were treated with transilluminated powered phlebectomy over a 7-year period. The patients were followed for 1 year postoperatively. The analyzed data included sex, age, body mass index, operative time (from skin incision to the application of elastic bandages on the legs for compression purposes), and postoperative complications.

Results

The mean operative time was 87.2 min for both limbs and 57.3 min for single limbs. The median number of incisions was five. Postoperative complications included an episode of cellulitis in 10 patients (2.2%), wound abscess in two patients (0.4%), hematoma in 15 patients (3.4%), residual veins in five patients (1.1%), cutaneous nerve damage in 10 patients (2.2%), and seroma in 13 patients (2.9%). No skin perforation and deep venous thrombosis were observed at the 1-year follow-up.

Conclusion

Transilluminated powered phlebectomy is an effective and safe method for the excision of varicosities.     

A Pilot Study Reporting Outcomes for Melanoma Patients of a Minimal Access Ilio-inguinal Dissection Technique Based on Two Incisions

Background

A modified procedure for ilio-inguinal regional lymph node dissection (I-I RLND) involving 2 small skin incisions was evaluated with the aim of assessing surgical and oncological noninferiority compared with the traditional single, longitudinal incision I-I RLND.

Materials and Methods

A total of 20 melanoma patients with positive groin lymph nodes who had traditional I-I RLND were compared with 20 patients who had a minimal access I-I RLND using 2 small surgical access incisions of 3–6 cm in length—one sited below and one above the inguinal ligament. Clinical, staging features, number of lymph nodes retrieved, length of hospital stay, time drains remained in situ, morbidity (wound infections, dehiscence, hematoma, seroma, and lymphedema), and disease free survival were compared.

Results

Patients in the groups were comparable with the exception that the minimal access I-I RLND group had a higher rate of AJCC stage N3 disease (60% vs 20%; P = .03) and more cases with extranodal spread (45% vs 15%; P = .041). After a median follow-up of 5 months (range 1–8) for the minimal access group and median 13 months (range 1–30) for the standard group there were no differences in disease-free survival (P = .13). Retrieved lymph node counts were similar (P = .34) including for the inguinal and pelvic components of the operations separately. No significant differences in wound complications or rates of early lymphedema were observed.

Conclusions

At early follow-up, minimal access I-I RLND is feasible and noninferior to single longitudinal incision I-I RLND in regard to surgical morbidity and oncological outcome. Further evaluation is progressing.     

Single-incision laparoscopic surgery: a promising approach to sigmoidectomy for diverticular disease

Background

Laparoscopic sigmoidectomy has become the standard procedure in elective surgery for recurrent diverticular disease. To realize further benefits of this minimal invasive procedure and to offer less postoperative pain, shorter recovery time, reduced complications, and improved cosmetic results, attempts are being made to minimize the number of necessary skin incisions for trocar positioning. One method is to use only one port for laparoscopic access to perform diverticular-related elective sigmoidectomies.

Methods

Between 7 July and 4 August 2009, 10 consecutive patients were referred for partial left colon resection due to multiple episodes of diverticulitis. In all cases, access to the abdomen was achieved through a 2- to 2.5-cm single incision via the umbilicus followed by insertion of the single-incision laparoscopic surgery (SILS?) port system. Outcomes such as change in the procedural method, operative time, postoperative complications, and length of stay were recorded.

Results

Of the 10 consecutive sigmoidectomies, 9 were performed successfully with the SILS? procedure using only one incision in the umbilicus. No mortalities or major complications were noted. The median operating time was 120 min, and the median postoperative hospital stay was 7 days.

Conclusion

As an alternative to the standard laparoscopic procedure, single-incision laparoscopic sigmoidectomy via the umbilicus is technically feasible and effective. This attractive procedure aims to increase the patient’s comfort further after abdominal surgery.