Surgeon Elective Abdominal Aortic Aneurysm Repair Volume and Outcomes of Ruptured Abdominal Aortic Aneurysm Repair: A 12-year Nationwide Study

Background

The purpose of the present study was to examine the effects of surgeon elective abdominal aortic aneurysm repair volume on outcomes after ruptured abdominal aortic aneurysm (rAAA) repair.

Methods

A nationwide claims database was used to identify patients who underwent rAAA repair from 1998 to 2009. Surgeon elective open abdominal aortic aneurysm repair (EAR) volume was classified as low, medium, or high. Associations between surgeon EAR volume and in-hospital mortality, overall survival, and complications after open rAAA repair (RAR) were compared with multivariate analysis. Associations between surgeon elective endovascular abdominal aortic aneurysm repair (EER) volume and outcomes after endovascular rAAA repair (RER) were also analyzed.

Results

A total of 537 patients who underwent rAAA repair were identified, including 498 who underwent RAR and 39 who underwent RER. In-hospital mortality rates after RAR were 49, 38, and 24 % in the low, medium, and high EAR volume groups, respectively (p < 0.001). Patients in the low surgeon EAR volume group had higher in-hospital mortality than those in the high surgeon EAR volume group [odds ratio 3.39, 95 % confidence interval (CI) 1.52, 7.59; p = 0.003]. Patients in the low surgeon EAR volume group also had higher long-term mortality (hazard ratio 1.86, 95 % CI 1.21, 2.85; p = 0.005). There were no significant differences in complication rates among the surgeon EAR volume groups or in-hospital mortality after RER among the surgeon EER volume groups.

Conclusions

Surgeon EAR volume is associated with in-hospital mortality and long-term survival after RAR.     

Long-Term Survival and Quality of Life After Open Abdominal Aortic Aneurysm Repair

Background

Open repair of abdominal aortic aneurysm (AAA) generally involves postsurgery admission to the intensive care unit (ICU). Few studies have evaluated the impact of surgery for either ruptured or nonruptured AAA (with postoperative ICU treatment) on long-term survival and quality of life. The primary aim of this study was to quantify long-term survival and health-related quality of life (HrQpL) of a cohort of patients undergoing open AAA repair after hospital discharge.

Methods

Consecutive patients undergoing open elective or acute AAA reconstruction with postoperative admission to the ICU and discharged alive from the hospital during 2009 were identified. Primary outcome measures were 1-year and long-term mortality. The secondary outcome was the HrQoL using the EuroQol-6D (EQ-6D) questionnaire at the end of the follow-up period.

Results

A total of 263 patients were treated and postoperatively discharged alive: 56 had a ruptured AAA (rAAA), 35 a symptomatic AAA, and 172 an asymptomatic AAA. The 1-year mortality after open AAA repair was 8 %. Overall, 39 % of patients died within 10 postoperative years (mean 6.0 ± 2.8 years). Long-term survival of patients with a ruptured or symptomatic aneurysm was similar to that of patients undergoing elective aneurysm repair. Long-term HrQoL of the total study population was worse than that of an age-matched general Dutch population on the EQ-us (range 0–1, difference 0.12). This decrease in HrQoL was mainly seen in mobility, self-care, usual activities, and cognition.

Conclusions

Ten years after open AAA repair, the overall survival rate was 59 %. Long-term survival and HrQoL were similar for patients with a repaired ruptured or symptomatic aneurysm and those who underwent elective aneurysm repair. There were also no differences in patients with infrarenal versus juxtarenal/suprarenal aneurysms. Surviving patients had a lower HrQoL than the age-matched general Dutch population, especially regarding mobility, self-care, usual activities, and cognition.     

Maximal aortic diameter affects outcome after endovascular repair of abdominal aortic aneurysms

Objective

The purpose of this study was to evaluate whether maximal aortic diameter affects outcome after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA).

Few internal iliac artery aneurysms rupture under 4 cm

Objective

This study investigated the diameter of internal iliac artery (IIA) aneurysms (IIAAs) at the time of rupture to evaluate whether the current threshold diameter for elective repair of 3 cm is reasonable. The prevalence of concomitant aneurysms and results of surgical treatment were also investigated.

Outcomes After Emergency Versus Elective Ventral Hernia Repair: A Prospective Nationwide Study

Background

Early surgical results after emergency repairs for the most frequent ventral hernias (epigastric, umbilical, and incisional) are not well described. Thus, the aim of present study was to investigate early results and risk factors for poor 30-day outcome after emergency versus elective repair for ventral hernias.

Methods

All patients undergoing epigastric, umbilical, or incisional hernia repair registered in the Danish Hernia Database during the period 1 January 2007 to 31 December 2010 were included in the prospective study. Follow-up was obtained through administrative data from the Danish National Patient Register.

Results

In total, 10,041 elective and 935 emergency repairs were included. The risk for 30-day mortality, reoperation, and readmission was significantly higher (by a factor 2–15) after emergency repairs than after elective repairs (p ≤ 0.003). In addition, there were significantly more patients with concomitant bowel resection after emergency repairs than after elective repairs (p < 0.001). Independent risk factors for emergency umbilical/epigastric hernia repair were female gender, older age, hernia defects >2–7 cm, and repair for a primary hernia (vs recurrent hernia) (all p < 0.05). Independent risk factors for emergency incisional hernia repair were female gender, increasing age, and hernia defects ≤7 cm (all p < 0.05).

Conclusions

Emergency umbilical/epigastric or incisional hernia repair was beset with up to 15-fold higher mortality, reoperation, and readmission rates than elective repair. Older age, female gender, and umbilical hernia defects between 2 and 7 cm or incisional hernia defects up to 7 cm were important risk factors for emergency repair.     

Laparoscopic aneurysm resection and splenectomy for splenic artery aneurysm in the third trimester of pregnancy

Background

Splenic artery aneurysms (SAA) are a rare entity most commonly diagnosed incidentally. Their association with pregnancy increases the risk of rupture resulting in a disproportionately high maternal and fetal mortality. Accordingly, elective surgical treatment is recommended in asymptomatic patients with aneurysms less than 2 cm. In this case, we present a patient during her third trimester of pregnancy with a SAA who was treated by laparoscopic aneurysm resection and splenectomy.

Methods

The patient is a 38-year-old multiparous woman, with an incidental diagnosis of a SAA in 2010. Subsequently, the patient became pregnant and at 27 weeks started to develop abdominal pain. Failed embolization was attempted with worsening of the patient’s symptoms. A CT angiogram revealed a 1.6 cm distal third SAA without any evidence of rupture. Due to the localization of the lesion, the patient was offered a laparoscopic aneurysm resection and splenectomy.

Results

Operating time was 90 min and estimated blood loss was 5 cc. Postoperative fetal monitoring was normal. No perioperative complications were observed. The patient was discharged on postoperative day 3. Two months after laparoscopic splenectomy, the patient delivered a male infant in perfect health.

Conclusions

Although this is a rare disease, the risk of aneurysmal rupture is increased during pregnancy. As a result of high maternal and fetal mortality, elective surgery should be performed. Laparoscopic surgery is the technique of choice.     

Introduction of cardiac surgery residency program at an earlier stage in surgical training

Objective

Reform of the Japanese postgraduate residency program has dramatically influenced the recruitment system. Because shortage of young cardiac surgeons is anticipated, an effective program for residents who want to become cardiac surgeons must be established at an earlier stage in surgical training.

Methods

A 3-year cardiac surgery residency curriculum was developed for senior residents. The surgical training program includes harvesting of the saphenous vein, radial artery and internal thoracic artery, and repair of abdominal aortic aneurysm and specifies the target number of surgical procedures for each training. Academic training is provided in addition to clinical skills training. Nine residents completed the 3-year program between 2004 and 2012. The number of surgical procedures performed, presentations made at scientific meetings, and scientific papers published were investigated and analyzed.

Results

Each resident participated in 438 operations during 3-year program, 25.9 ± 8.3 (5.9 %) as main operator and 182.2 ± 15.8 (42 %) as first assistant. The average number of procedures per resident over the 3 years was 43.0 ± 6.7 for saphenous vein harvest, 14.4 ± 3.9 for radial artery harvest, 27.9 ± 13.0 for internal thoracic artery harvest, 7.1 ± 4.6 for abdominal aortic aneurysm. In addition, over the 3 years, the mean number of presentations at scientific meetings was 13.2 ± 3.2 and the mean number of publication of scientific papers was 1.9 ± 1.4.

Conclusion

The new cardiac surgery training curriculum for residents worked fairly well. A system for assessment of the program by an authoritative body should be established in the future.     

Right axillary arterial perfusion for descending thoracic or thoracoabdominal aortic aneurysm repair with open proximal anastomosis through left thoracotomy

Background

We examined the effectiveness of right axillary arterial perfusion through an interposed Dacron graft in the prevention of cerebral embolism or complications related to ascending aortic cannulation in open proximal anastomosis technique of descending thoracic aortic aneurysm (TAA) or thoracoabdominal aortic aneurysm (TAAA) repair under deep hypothermic circulatory arrest through left thoracotomy.

Methods

Between May 2000 and August 2012, 44 patients underwent TAA or TAAA repair using open proximal technique under DHCA. These patients were divided into two groups for evaluation of the effectiveness of right axillary arterial perfusion. Group A included patients who underwent TAA or TAAA repair with ascending aortic cannulation (n = 15). Group B was composed of patients who had TAA or TAAA repair with right axillary arterial perfusion through the interposed Dacron graft (n = 29).

Results

Mortality in this series was 4.5 % (2 of 44 patients; 1 in each group); wherein, the causes were sepsis due to graft infection and aortic dissection (Stanford type A). The incidence rates of cerebral embolism were 27 % (4 of 15 patients in group A) and 3.4 % (1 of 29 patients in group B) (p = 0.0392, Fisher’s exact test). The rates of complications in relation to the aortic cannulation site (dissection or bleeding) were 13 % (2 of 15 patients in group A) and 0 % (0 of 25 patients in group B).

Conclusions

Right axillary perfusion facilitates easy evacuation of air and allows prompt recommencement of upper body circulation. Consequently, it minimizes the risk of cerebral embolism or complications in relation to aortic cannulation through left thoracotomy.     

Role of Pre-operative Multiple Gated Acquisition Scanning in Predicting Long-Term Outcome in Patients Undergoing Elective Abdominal Aortic Aneurysm Repair

Objective

To determine whether resting pre-operative left ventricular ejection fraction (LVEF) estimated by multiple gated acquisition scanning (MUGA) predicts long-term survival in patients undergoing elective abdominal aortic aneurysm (AAA) repair.

Methods

A retrospective study of MUGA scans which were performed to estimate pre-operative resting LVEF in 127 patients [106 (83 %) males, mean age 74 ± 7.6 years] who underwent elective AAA repair over a period of 4 years from March 2007. We compared outcomes and long-term survival between patients who had a pre-operative LVEF ≤ 40 % (Group 1, n = 60) and LVEF > 40 % (Group 2, n = 67).

Results

Overall 19 (15 %) patients died during the follow-up period (13 patients in group 1 and 6 patients in group 2). 30-day mortality was 8 %. There was no significant difference between group 1 and 2 in terms of patients’ mean age or median length of hospital stay (8 days for both groups, p = 0.61). However, group 2 had more females than group 1(18 vs. 3, p = 0.001). Median survival for patients in group 2 was significantly higher than patients in group 1 (1,258 days vs. 1,000 days, p = 0.03). In a Cox regression model which included age, sex, smoking status and LVEF as covariates, only smoking status and LVEF predicted survival [Hazard ratio (HR) = 1.06, p = 0.04 and HR = 0.93, p = 0.00, respectively].

Conclusion

This study shows that there is a role for pre-operative MUGA scan assessment of resting LVEF in predicting long-term survival post elective AAA repair and that the lower the pre-operative LVEF the poorer the long-term outcome.     

Laparoscopic repair of complex ventral hernia facilitated by pre-operative chemical component relaxation using <Emphasis Type="Italic">Botulinum Toxin A</Emphasis>

Purpose

The operative management of complex ventral hernia poses a formidable challenge, despite recent advances in surgical techniques. Recurrence rates after complex ventral hernia repair remain high, and increase with each failed attempt. This study examines the effect of pre-operative abdominal wall chemical component relaxation using Botulinum Toxin A (BTA) to induce temporary flaccid paralysis in order to facilitate laparoscopic repair of large complex ventral hernia.

Methods

This is a prospective evaluation of 27 patients from January 2013 to August 2015 who underwent ultrasound guided BTA injections to the lateral abdominal wall muscles prior to elective complex ventral hernia repair. Non-contrast serial CT imaging was obtained pre- and post-BTA injection to measure change in fascial defect size and abdominal wall muscle thickness and length. Fascial defects were closed and hernias repaired using laparoscopic or laparoscopic-assisted intra-peritoneal onlay mesh (IPOM) techniques.

Results

27 patients received pre-operative BTA injections which were well tolerated with no complications. Comparison of pre-BTA and post-BTA CT imaging demonstrated a significant increase in mean length of the lateral abdominal wall from 15.7 cm pre-BTA to 19.9 cm post-BTA (p < 0.0001), with mean unstretched length gain of 4.2 cm/side (range 0–11.7 cm/side). All hernias were surgically reduced and repaired with mesh, with no early recurrences.

Conclusion

Pre-operative administration of BTA is a safe and effective technique in the pre-operative preparation of patients undergoing elective complex ventral hernia repair. This technique lengthens and relaxes the laterally retracted abdominal muscles and enables laparoscopic closure of large complex ventral hernia.

     

Medikamentöse Therapie zur Risikoreduktion und Progressionshemmung nicht interventionspflichtiger abdomineller Aortenaneurysmen

Background

An ultrasound screening examination is highly effective in the detection of abdominal aortic aneurysms (AAA) in males above the age of 65 years. Patients with small AAAs (diameter Objectives The effectiveness of medicinal treatment approaches on the overall cardiovascular risk and on the growth and rupture rate of small AAAs was analyzed.

Material and methods

This article presents and discusses the currently available literature on the effectiveness of medicinal treatment of small AAAs.

Results

Statins, beta blockers and angiotensin-converting enzyme (ACE) inhibitors reduce cardiovascular mortality in patients with AAAs and statins also reduce the growth rate of AAAs.

Conclusion

Screening programs must implement strategies to improve total cardiovascular prognosis of patients with small AAAs.     

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.     

Sex differences in mortality and morbidity following repair of intact abdominal aortic aneurysms

Objective

Medicare studies have shown increased perioperative mortality in women compared with men following endovascular and open abdominal aortic aneurysm (AAA) repair. However, a recent regional study of high-volume centers, adjusting for anatomy but limited in sample size, did not show sex to be predictive of worse outcomes. This study aimed to evaluate sex differences after intact AAA repair in a national clinical registry.

Long-term complaints after elective repair for small umbilical or epigastric hernias

Purpose

Elective repair for umbilical or epigastric hernia is a frequent minor surgical procedure. Several studies have demonstrated chronic pain after groin hernia repair but long-term complaints have been only scarcely studied. This study was undertaken to investigate long-term pain and discomfort after open repair for small umbilical or epigastric hernias.

Methods

This is a retrospective study with prospective long-term follow-up. Only elective primary umbilical or epigastric hernias with an open mesh or sutured repair were included. A structured follow-up questionnaire was sent to all patients regarding verbal rating scores (VRS) of pain and discomfort (no, little, moderate, or severe) and recurrence. Patients with suspected recurrence were clinically examined.

Results

There were 139 eligible patients, and 132 patients answered the questionnaire (95 % response rate). The median follow-up time was 36 months (range 15–85), and defect size was 1.0 cm (0.2–8.0). Sixteen patients reported moderate or severe pain and/or discomfort (12 %, 95 % confidence interval (CI): 6–18). The cumulated risk of recurrence was 11.5 %. Of the 15 patients with clinical recurrence or reoperation for recurrence, 5 patients reported moderate/severe complaints (31 %) whereas 11 of the remaining 116 patients with no recurrence (10 %) reported moderate/severe complaints (P = 0.014).

Conclusion

Surprisingly, many patients complained about pain and discomfort 3 years after elective repair for a small umbilical or epigastric hernia.     

Vesicouterine fistulae: our experience of 17 cases and literature review

Aim

A retrospective study of vesicouterine fistulae managed from 1996 to 2011 analyzed the incidence, symptomatology, diagnosis, and surgical outcome.

Patients & methods

During the study period, 17 patients were managed, of whom 14 underwent abdominal repair and three underwent vaginal repair. Mean patient age was 31.1 years and mean follow-up 7.3 years.

Results

Vesicouterine fistulae resulted following cesarean section in 13 patients and vaginal delivery in four. Eleven patients presented with urinary leakage via the vagina and seven with menouria. All patients had successful outcomes irrespective of treatment approach. The uterus was conserved in ten patients, of whom seven had completed their childbearing. The remaining three conceived spontaneously and underwent elective cesarean section.

Conclusion

The majority of vesicouterine fistulae occur following cesarean section, and it is feasible to achieve 100 % successful repair. Though the majority require abdominal repair, a few selected cases can be successfully repaired vaginally.     

Acute kidney injury after abdominal aortic aneurysm repair: current epidemiology and potential prevention

Purpose

Acute kidney injury (AKI) is a severe complication after infrarenal abdominal aortic aneurysm (iAAA) repair. Little data are available whether endovascular aneurysm (EVAR) or open aortic repair (OAR) differs with respect to AKI frequency and severity, consecutive development of chronic kidney disease (CKD) and potentially preventable and modifiable risk factors of AKI.

Patients and methods

We assessed AKI rates, AKI stages and CKD applying current, complete definitions from the kidney disease improving global outcomes initiative in propensity-score-matched cohorts of all patients with elective and urgent iAAA repair at our institution from 2007 to 2011. Risk factors were analysed using multivariate logistic regression analyses.

Results

From 268 patients, we identified 91 matched pairs who had undergone either EVAR or OAR. The AKI rate was 13.2% with EVAR versus 41.8% with OAR (P < 0.001). AKI was significantly less severe in EVAR. OAR patients lost more glomerular filtration rate (? 11.3 vs. ? 6.5%; P = 0.02) and developed more frequently CKD (14.3 vs. 3.2%; P < 0.001) 3 months after iAAA repair. EVAR, circulatory shock, radiocontrast media, rhabdomyolysis and sepsis were identified as potentially preventable or modifiable risk factors of AKI.

Conclusions

AKI is significantly less frequent and severe in iAAA patients after EVAR as compared to OAR. Furthermore OAR patients demonstrate a higher CKD rate. The identified risk factors may be prevented or modified as a bundle of measures especially in patients with pre-existing CKD to reduce AKI and its severity after iAAA repair.

     

Surgical repair of Kommerell’s diverticulum and an aberrant subclavian artery

Purpose

The coexistence of Kommerell’s diverticulum and an aberrant subclavian artery (ASCA) is a rare congenital variation of the vascular structure. We report our experience of treating aneurysms associated with these anomalies.

Methods

Between June 2007 and November 2011, five consecutive patients underwent repair of an aneurysm associated with Kommerell’s diverticulum and an ASCA at Shiga University Hospital. Four of the five patients had a right-sided aortic arch associated with the ASCA. One patient underwent emergency surgery for a ruptured thoracic aneurysm. The operations performed were descending aorta replacement through right thoracotomy in one patient and total arch replacement through a median thoracotomy, under deep hypothermic circulatory arrest and selective cerebral perfusion, in four patients. No staged operation was required.

Results

One patient died of mediastinitis, subsequent to a ruptured Kommerell’s diverticulum, 45 days postoperatively. There were no other deaths in the early or late (6–58 months) postoperative period. One patient required re-exploration for bleeding, but none of the patients suffered neurologic complications.

Conclusions

Aortic disease with an ASCA and Kommerell’s diverticulum can be repaired safely under elective conditions.     

Embolic complications after endovascular repair of abdominal aortic aneurysms

Purpose

This retrospective study aimed to review our experiences with endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs), along with the incidence, risk factors and prognoses of associated embolic events. Our goal was to present the EVAR results and related risk factors from a single center, with a focus on embolic complications.

Methods

We retrospectively reviewed the data of 539 patients with AAAs who underwent elective EVAR at Jikei University from July 2006 to April 2009. Of these, 438 patients were selected after excluding those requiring fenestrated and branched EVAR.

Results

The technical success rate was 91.1 % (399/438) with no surgical mortality. Embolic complications occurred in nine patients (2 %), four of whom developed ischemic colitis and were successfully treated with bowel rest and hydration. Lower extremity atheroembolization and stroke occurred in three and one patients, respectively. Two patients died of cholesterol crystal embolization. Seven of the nine embolic complications (77.8 %) were associated with the use of Zenith stent-grafts. A Cox proportional-hazard regression analysis of the adjusted risk factors showed that smoking and severe arterial degeneration of the aorta, referred to as a shaggy aorta, to be independent predictors of embolic complications.

Conclusions

The presence of a shaggy aorta and a history of smoking are independent predictors of embolic complications associated with EVAR.     

Open and endovascular elective treatment of abdominal aortic aneurysms: a real-world experience

Purpose

To present a real-world experience of the elective treatment of abdominal aortic aneurysms (AAAs) using both open repair (OR) and endovascular repair (EVAR).

Methods

Data from patients treated consecutively between January 1, 2000 and December 31, 2014 were collected retrospectively and reviewed. The primary outcomes were 30-day mortality and complication rates, freedom from reintervention, and survival in the long-term.

Results

We analyzed data on 1112 patients (660 EVAR, 452 OR). The 30-day mortality and complications rates were higher after OR than after EVAR (2.9 vs. 1.1%, P?=?.03 and 24.7 vs. 1.1%, P?<?.0001, respectively). At 10 years, survival was 66.1 ± 3.2% after OR and 78.1 ± 2.2% after EVAR (P?=?.0006) and freedom from reintervention was 93.5 ± 1.8% after OR and 88.4 ± 1.8% after EVAR (P?=?.005). The preoperative aneurysm diameter was significantly associated with the development of type Ia endoleaks after EVAR (P?<?.0001) and of a proximal pseudoaneurysm after OR (P?<?.0001).

Conclusion

In the long-term, EVAR was associated with higher reintervention rates, but better survival than OR. The preoperative AAA diameter was the most important predictor of the development of endoleaks after EVAR and proximal pseudoaneurysm after OR.

     

Multilayer Myofascial-Mesh Repair for Giant Midline Incisional Hernias: A Novel Advantageous Combination of Old and New Techniques

Background

The components separation technique has been proposed as the best solution when facing large abdominal wall defects. In counterpart, this sometimes comes at the price of high rates of wound complications and recurrence. Moreover, the components separation method alone seems insufficient for huge defects, in which it is impossible to reapproximate the rectus muscles without tension. For these cases, we illustrate a novel operation using a modified components separation technique.

Methods

Twenty-eight patients with giant midline incisional hernias were treated with a combination of the components separation (bilateral sliding rectus abdominis advancement flaps), an autologous multilayer repair, and a retromuscular mesh reinforcement.

Results

Twenty-four (85 %) patients have been analyzed. Transverse defect size ranged from 15 to 25 cm (average, 18.8 cm). Wound complications occurred in nine (37 %) cases; three of them required drainage of a subcutaneous abscess. After a mean follow-up of 22 (range, 12–48)?months, one (4 %) recurrence was identified.

Conclusions

Multilayer myofascial-mesh repair was associated with a low recurrence rate, and wound complications were managed without issues. This approach is a reliable technique for most surgeons and may constitute a new part of the armamentarium for the repair of challenging defects.