Transvaginal native-tissue repair of enterocele

Introduction and hypothesis

Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS).

Methods

A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique.

Results

Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how.

Conclusions

Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.

     

A deep azygoesophageal recess may increase the risk of secondary spontaneous pneumothorax

Purpose

The azygoesophageal recess (AER) is known as a possible cause of bulla formation in patients with spontaneous pneumothorax. However, there has been little focus on the depth of the AER. We evaluated the relationship between the depth of the AER and pneumothorax development.

Methods

We conducted a retrospective study of 80 spontaneous pneumothorax patients who underwent surgery at our institution. We evaluated the depth of the AER on preoperative computed tomography scans.

Results

Ruptured bullae at the AER were found in 12 patients (52.2%) with secondary spontaneous pneumothorax (SSP) and 8 patients (14.0%) with primary spontaneous pneumothorax (PSP) (p?<?0.001). In patients with ruptured bullae at the AER, 10 SSP patients (83.3%) had a deep AER while only 2 PSP patients (25%) had a deep AER (p?=?0.015).

Conclusions

A deep AER was more frequently associated with SSP than with PSP. A deep AER may contributes to bulla formation and rupture in SSP patients.

     

A simplified surgical technique for recurrent inguinal hernia repair following total extraperitoneal patch plastic

Purpose

To present a new and alternative method for surgical treatment of recurrent inguinal hernia after total extraperitoneal patch plastic (TEP).

Methods

From January 2005 to September 2015, 35 patients (34 male, 1 female; mean age 65 ± 12.6 years) with recurrent inguinal hernia following TEP were operated at the Kliniken Essen-Mitte using a simplified method consisting of re-fixation of the primary mesh to the inguinal ligament by an anterior approach.

Results

The mean operating time was 47 ± 22 min. All complications were minor with an overall incidence of 6%. After a mean follow-up of 54 months one re-recurrence was observed.

Conclusions

This Simplified Hernia Repair is safe and avoids additional foreign body implantation. Therefore, it is our method of choice for recurrent inguinal hernias after TEP.

     

Anteriorly based pudendal thigh flap for scrotal reconstruction based on the deep external pudendal artery (DEPA) flap

Background

Major scrotal skin loss represents a significant challenge for reconstructive surgeons. Although many therapeutic methods have been established for the treatment of such defects, each technique has its own advantages and disadvantages. A posteriorly based pudendal thigh fasciocutaneous flap at the perianal region has been described for reconstruction of genital organs, but an anteriorly based pudendal thigh fasciocutaneous flap has not been described for scrotal reconstruction.

Aim

The aim of this study was to introduce and evaluate the use of an anteriorly based pudendal thigh flap for scrotal reconstruction.

Methods

Twenty flaps in 15 patients with major scrotal defects were subjected to reconstruction using this flap. The etiology of scrotal loss was Fournier gangrene in all cases. Five patients each underwent bilateral and ten patient unilateral reconstructions, by the anteriorly based pudendal thigh flap, based on the deep external pudendal artery (DEPA).

Results

All 20 flaps survived completely. Additionally, the donor site was closed directly, and the scar was hidden in the perineal crease. The donor site healed uneventfully, as one patient required a secondary procedure for healing.

Conclusion

An anteriorly based pudendal thigh flap is highly reliable for coverage of major scrotal defects. This flap allows adequate coverage with excellent aesthetic appearance of the scrotum.Level of Evidence: Level II, therapeutic study.

     

Die ergänzende Mittelgelenkarthrolyse bei der operativen Behandlung einer Dupuytren’schen Beugekontraktur am Finger

Objective

Correction of residual flexion deformity of the proximal interphalangeal (PIP) joint after excision of diseased connective tissue in Dupuytren’s contracture by stepwise arthrolysis.

Indications

Flexion deformity of the PIP joint of 20° or more after excision of the diseased connective tissue in Dupuytren’s contracture.

Contraindications

Joint deformities, osteoarthrosis, intrinsic muscle contracture, instability of the PIP joint.

Surgical technique

Arthrolysis of the PIP joint is performed by six consecutive steps: dissection of the remaining skin ligaments, opening the flexor tendon sheath by transverse incision at the distal end of the A2 pulley, dissection of the checkrein ligaments, dissection of the accessory collateral ligaments, releasing the palmar plate proximally, releasing the palmar plate up to its insertion at the middle phalanx base.

Postoperative management

Dorsal plaster of Paris with extended fingers and compressive dressing in the palm for 2 days, occupational/physical therapy, static and possible dynamic extension splint several weeks/months.

Results

A total of 31 fingers in 28 patients with Dupuytren’s contracture were evaluated an average of 22 months after arthrolysis of the PIP joint. In all, 26 joints with an average recurrent flexion contracture of 29° were improved compared to the preoperative flexion contracture of 81°; 4 PIP joints with a recurrent flexion contracture averaging 60° were worse. In one patient, PIP flexion contracture of 90° was unchanged at follow-up although the joint could be extended intraoperatively to 10° of flexion.

     

Management of late-onset deep surgical site infection after instrumented spinal surgery

Background

There are no universally accepted protocols for the treatment of late-onset deep surgical site infection. This study retrospectively evaluates the methods of aggressive debridement with instrumentation retention, high vacuum closed-suction drain without irrigation, primary wound closure, and antibiotic therapy for the treatment of late-onset deep surgical site infection after instrumented spinal surgery.

Methods

A total of 4057 patients who underwent instrumented spinal surgeries were surveyed from January 2010 to June 2014. Surgical debridement was performed immediately after late-onset deep surgical site infection was identified. In addition to extended resection of the devitalized and necrotic tissue, the biofilms adhered to the surface of implants were removed meticulously and thoroughly. Primary wound closure was performed on each patient, and closed suction drains were maintained for about 7–10?days without irrigation. Antibiotic therapy was administered for 3?months according to the results of the pathogenic culture.

Results

Forty-two patients were identified as having late-onset deep surgical site infection. Staphylococcus aureus was the most common pathogen in this group. Seven patients with late-onset deep surgical site infection had negative bacterial culture results. Infections resolved in all patients. Forty-one patients retained their instrumentation, whereas 1 patient had the implants removed because of Staphylococcus aureus infection, which was found the implants loosening during debridement. Primary wound healing was found in all patients with no recurrence of infection during the follow-up periods.

Conclusions

A timely diagnosis, aggressive and meticulous debridement, high vacuum closed-suction drain, routine and adequate use of antibacterial agents are the keys to successfully resolving infection and keeping implants retention in the treatment of late-onset deep surgical site infection after instrumented spinal surgery.

     

Arthroscopic treatment for ulnar-sided TFCC-tears

Objective

Ruptures of ulnar-sided triangular fibrocartilaginous complex (TFCC) often occur in cases of trauma. Golden standard for diagnosis is the arthroscopy of the wrist. TFCC lesions are classified according to their location if traumatic in origin or if degenerative according to their severity.

Materials and methods

Recent literature has focused on the ruptures of ulnar-sided triangular fibrocartilaginous complex. This article describes conservative, operative and arthroscopic surgical techniques to reconstruct the triangular fibrocartilaginous complex and restore distal radioulnar joint stability.

Results

The main therapeutic goal should be the stabilization of the DRUJ by reattachment of the torn ligaments in ulnar-sided ruptures to the deep fibers in the fovea. This reinsertion can be performed by transosseous suture, a suture anchor or open.

Conclusion

Central TFCC tears are typically located close to the sigmoid notch of the radius and are either traumatic or degenerative in origin. While central TFCC lesions are usually treated by arthroscopic debridement using small joint punches or a bipolar high frequency system, the ulnar TFCC avulsions can also be refixed arthroscopically in different techniques.

     

Adjacent segment pathology: natural history or effect of anterior cervical discectomy and fusion? A 10-year follow-up radiological multicenter study using an evaluation scale of the ageing spine

Purpose

Aim of this study is to compare late degenerative MRI changes in a subset of patients operated on with ACDF to a second subset of patients presenting indication to ACDF but never operated on.

Methods

Patients from both subgroups received surgical indication according to the same criteria. Both subgroups underwent a cervical spine MRI in 2004–2005 and 10 years later in 2015. These MRI scans were retrospectively evaluated with a cervical spine ageing scale.

Results

Comparing the two subset of patients both suffering from clinically relevant single-level disease returns no statistically significant difference in the degenerative condition of posterior ligaments, presence of degenerative spondylolisthesis, foraminal stenosis, diameter of the spinal canal, Modic alteration, and intervertebral discs degeneration at 10-year follow-up.

Conclusions

The adjacent segment degeneration represents, in the present cohort, a result of the natural history of cervical spondylosis rather than a consequence of fusion.

     

Transvaginal uterosacral ligament hysteropexy: a video tutorial

Introduction and hypothesis

Uterine-sparing procedures could be attractive in patients concerned about fertility preservation and corporeal image changes. Transvaginal uterosacral ligaments (USLs) hysteropexy can provide a mesh-free technique for uterine suspension. This video is intended to serve as a tutorial for surgical steps.

Methods

A 38-year-old woman with symptomatic stage III POP desired preserving fertility. After proper counseling, the patient was admitted for vaginal hysteropexy through bilateral high USL suspension according to the featured technique.

Results

Prolapse repair was successfully achieved without complications. We had already published a series of 20 cases that confirmed that transvaginal USLs hysteropexy is a promising technique for correcting genital prolapse with uterus preservation.

Conclusion

Transvaginal USLs hysteropexy provides a feasible technique for apical support without the use of prosthetic material. This procedure could be attractive to women who desire a uterine-sparing surgical option.

     

Results of the modified bi-pectoral muscle flap procedure for post-sternotomy deep wound infection

Purpose

Post-sternotomy deep sternal wound infection (DSWI) is a severe complication of cardiac surgery. The introduction of omental and muscle flaps has resulted in a significant decrease in morbidity and mortality. In this article, we present the findings for a series of 55 consecutive patients with DSWI treated using an alternative bi-pectoral musculofascial flap technique.

Methods

The patients were stratified into two groups (one-or two-stage intervention). Patients with septic wounds initially underwent debridement and wound treatment, while vacuum therapy was used in a subset of the subjects. All patients were treated with wound debridement and bi-pectoral advancement flap reconstruction.

Results

30-day mortality was 5.4 %. Most patients (72 %) were treated in two stages, while vacuum therapy was used in 20 % of the patients. The mean number of hospitalization days was 8 and 12 for the one- and the two-stage groups, respectively. Reconstruction was successful in all but three patients, each of whom developed recurrent infection. No major morbidity was reported at a mean follow-up of 82 months with excellent functional and aesthetic outcomes.

Conclusions

Pectoralis-major muscle flaps remain relevant in the modern management of post-sternotomy mediastinitis. The addition of an omental flap should be considered in cases in which the lower sternum is involved. Prompt diagnosis and a meticulous surgical technique ensure favorable results for the majority of patients.

     

Mechanical role of the posterior column components in the cervical spine

Purpose

To quantify the mechanical role of posterior column components in human cervical spine segments.

Methods

Twelve C6-7 segments were subjected to resection of (1) suprasinous/interspinous ligaments (SSL/ISL), (2) ligamenta flavum (LF), (3) facet capsules, and (4) facets. A robot-based testing system performed repeated flexibility testing of flexion–extension (FE), axial rotation (AR), and lateral bending (LB) to 2.5Nm and replayed kinematics from intact flexibility tests for each state. Range-of-motion, stiffness, moment resistance and resultant forces were calculated.

Results

The LF contributes largely to moment resistance, particularly in flexion. Facet joints were primary contributors to AR and LB mechanics. Moment/force responses were more sensitive and precise than kinematic outcomes.

Conclusions

The LF is mechanically important in the cervical spine; its injury could negatively impact load distribution. Damage to facets in a flexion injury could lead to AR or LB hypermobility. Quantifying the contribution of spinal structures to moment resistance is a sensitive, precise process for characterizing structural mechanics.

     

Evaluation and Treatment of Superficial Esophageal Cancer

Introduction

Adenocarcinoma of the esophagus is the fastest increasing cancer in the USA, and an increasing number of patients are identified with early-stage disease. The evaluation and treatment of these superficial cancers differs from local and regionally advanced lesions.

Methods

This paper is a review of the current methods to diagnose, stage, and treat superficial esophageal adenocarcinoma.

Results

Intramucosal adenocarcinoma can be effectively treated with endoscopic resection techniques and with less morbid surgical options including a vagal-sparing esophagectomy. However, submucosal lesions are associated with a significant risk for lymph node metastases and are best treated with esophagectomy and lymphadenectomy.

Discussion

There has been a major shift in the treatment for Barrett’s high-grade dysplasia and superficial esophageal adenocarcinoma in the past 10 years. New therapies minimize the morbidity and mortality of traditional forms of esophagectomy and in some cases allow esophageal preservation. Individualization of therapy will allow maximization of successful outcome and quality of life with minimization of complications and recurrence of Barrett’s or cancer.

     

Total aortic arch replacement using hypothermic circulatory arrest with antegrade selective cerebral perfusion: are there cerebral deficits other than frank stroke?

Background

It is controversial whether cerebral deficits other than frank stroke develop after total aortic arch replacement using hypothermic circulatory arrest (HCA) with antegrade selective cerebral perfusion (SCP).

Objectives

We investigated neuropsychological functions in patients who received total aortic arch replacement using deep HCA with SCP.

Methods

Eleven patients who underwent elective total arch replacement using deep HCA with antegrade SCP were included. Cognitive functions of the patients were evaluated at baseline, and 3 weeks and 6 months after the aortic arch surgery.

Results

The performance of cognitive tests did not change 3 weeks after surgery, except for the attention/calculation task of the Mini-Mental State Examination (MMSE). Six months after surgery, the decline in score for the attention/calculation task in the MMSE had reversed and the score for this task as well as for all other tests had returned to baseline levels.

Conclusion

Long-lasting cognitive deficits other than frank stroke may not develop after total arch replacement surgery using deep HCA with SCP.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.

     

Pregnancy impact on uterosacral ligament and pelvic muscles using a 3D numerical and finite element model: preliminary results

Introduction and hypothesis

We studied the geometry of and changes in structures that play an important role in stabilizing the pelvic system during pregnancy using a numerical system at different gestational ages and postpartum.

Methods

We developed a parturient numerical model to assess pelvic structures at different gestational stages (16, 32, and 38 weeks) and postpartum (2 months and 1 year) using magnetic resonance imaging (MRI). Organs, muscles, and ligaments were segmented to generate a 3D model of the pelvis. We studied changes in the length of uterosacral ligaments (USL) and thickness of the puborectal portion of the levator ani muscle (LAM) during and after pregnancy. We used this model to perform finite element (FE) simulation and analyze deformations of these structures under stress from the increase in uterine weight.

Results

Analysis reveals an increase in the length of US ligaments at 16, 32, and 38 weeks. Two months after delivery, it decreases without returning to the length at 16 weeks of pregnancy. Similar changes were observed for the puborectal portion of the LAM. Variations observed in these structures are not equivalent to other anatomical structures of pelvic suspension. FE simulation with increased uterus weight does not lead to those findings.

Conclusion

This analysis brings new elements and a new focus for discussion relating to changes in pelvic balance of parturient women that are not simply linked to the increase in uterine volume.

     

Kindliche kniegelenknahe Avulsionen

Background

Avulsion fractures around the knee in children and adolescents are rare injuries and usually occur during sport activities. This article describes the epidemiology, classification and current treatment strategies for these injuries.

Objective

This article gives an overview of the epidemiology, classification and current treatment concepts of pediatric avulsion fractures around the knee.

Results

The most frequent pediatric avulsion fractures around the knee affect the tibial tuberosity and both the anterior and posterior cruciate ligaments. Bony avulsion of the cruciate ligaments can be classified according to Meyers and McKeever. In many cases there are indications for surgical treatment but non-dislocated fractures can be conservatively treated. Apophyseal fractures of the tibial tuberosity are as a rule repositioned by an open procedure followed by fixation with screws. The options for surgical treatment of bony avulsion of the cruciate ligaments are manifold, ranging from direct open screw fixation to bone anchoring and arthroscopic repositioning with suture cerclage. The advantages of arthroscopic procedures are the possibility to simultaneously treat unilateral accompanying injuries, such as meniscus ruptures.

Conclusion

Non-dislocated pediatric avulsion injuries near the knee can be treated conservatively under regular clinical and radiological follow-up control. Dislocated avulsions and non-dislocated avulsions with accompanying injuries are surgically treated. Arthroscopic procedures should be a standard procedure with respect to bony avulsion of the anterior cruciate ligament. In contrast, bony avulsion of the posterior cruciate ligament and injuries of the tibial tuberosity must be addressed rapidly and effectively with direct open repositioning.

     

Successful Surgical Treatment of Intractable Chylous Ascites Using the Lymphatic Cable Flap: A Retrospective Review Study

Objective

For evaluation of a novel surgical procedure for the treatment of chylous ascites.

Summary background data

Chylous ascites is a debilitating condition associated with high morbidity and mortality rates. At least one-third of patients are refractory to medical therapy and may warrant further treatment. Traditional methods involving ligation of lymphatic fistulas or small bowel resection do not address the basic pathophysiologic mechanism of the underlying obstruction, and identification of chyloperitoneal fistulas may be challenging.

Methods

A novel flap based on deep inferior epigastric vessels with its surrounding lymphatic fatty tissue was designed in this study and transferred into abdominal cavity, with anastomosis to the fourth jejunal vessels. Three consecutive cases with chylous ascites treated by this vascularized lymphatic cable transfer were retrospectively reviewed.

Results

All three patients recovered from chylous ascites after the lymphatic cable transfer and tolerated regular diet well, with follow-up of 3 years at least.

Conclusions

Lymphatic cable flap based on the deep inferior epigastric vessels could be a potential option for treatment of intractable chylous ascites, with safe and successful long-term outcomes in three consecutive patients. The proposed functional mechanism of the flap is bypass of the obstructed intra-abdominal lymphatics to an extraperitoneal route as well as local lymphangiogenesis.