The modified B-mammoplasty incision: an alternative skin-conserving technique for mastectomy with immediate breast reconstruction.

A modification of the B-mammoplasty incision (originally described by Regnault for reduction mammoplasty) is presented for patients undergoing skin-conserving mastectomy and reconstruction. This approach has several advantages; not only does it facilitate good exposure for the oncological surgeon to carry out the mastectomy, but it can easily be extended into the axilla to allow nodal clearance and microvascular access. It creates a suitable pocket into which a flap can be tailored or implant/expander inserted, and further adjustment of the breast size or shape can be undertaken easily. Most importantly, the scar is confined to the infralateral aspect of the breast, leaving the aesthetically important upper and medial breast skin scar free.     

The Marshall technique: an economic one-stage technique for nipple-areola reconstruction.

The goals of nipple-areola reconstruction are symmetry in position, shape, size, colour, tone, texture, sensation and responsiveness. These goals are best attempted when the breast-mound reconstruction has been completed. We describe a technique in which the skin of the neo-areola is raised as a split-thickness skin graft, and then re-grafted to the same site with a free nipple graft. This technique is always available, requires no special equipment, causes no donor-site morbidity and produces excellent results. The disadvantage is that it may be more difficult following radiotherapy or if the mastectomy scar traverses the desired site of nipple-areola reconstruction. As with any skin graft, the neo-areola may lose pigmentation, imperfectly 'take' or contract with time. This technique has not been previously described in the literature.     

Through-the-knee amputation: an improved technique

Through-the-knee amputation (TKA) is an excellent lower extremity treatment for the ischemic extremity when revascularization is not feasible and a prosthesis is not practical. Over the past 8 years 185 major amputations have been performed at our hospital of which 63 were of the TKA type. In 61 of these an improved technique was used that resulted in nonischemic, strong, and aesthetic stumps with 100 per cent primary healing. Our technique consists of removing the distal 2 cm of the femoral head with the two condyles and allowing the patella to ankylose to the new distal femoral end. In comparison with the other major amputations the TKA with this technique had significant advantages over the above-knee amputation and often was found to be superior to the below-knee amputation especially when rehabilitative ambulation with a prosthesis was not possible.     

Endoscopic urethroplasty: an improved technique

Endoscopic urethroplasty is an excellent alternative to open repair of the traumatically disrupted posterior urethra. It offers the advantage of limiting surgical trauma to an already scarred urethra and pelvic floor. Our technique also allows fluoroscopic guidance of the recanalization procedure to align the new urethral channel precisely with minimum disruption of the nerves and muscles of the periurethral tissue and pelvic floor. It obviates the need for a second surgeon viewing the urethra from above as has been required in previously described techniques. This procedure allows for maximal preservation of residual post-traumatic continence and erectile function because it minimizes blind passage of instruments.     

Definition of the inframammary fold in breast reconstruction: a simplified option

Background:

Redefinition of the inframammary fold in post-mastectomy reconstruction is an essential element to achieve construction of a natural-looking breast, either using implants and autologous tissue. Over years many techniques have been described scheduling external surgical approach (through incisions being made directly on the fold) or internal surgical approach (through the scar of previous procedure for breast expander positioning) and using running sutures or suture with interrupted stitches.

Methods:

A modified technique for redefinition of the inframammary fold using an internal approach was performed in 130 breast reconstruction procedures. Cosmetic outcomes and stability over time were assesed.

Results:

No total collapse was observed. The outcomes were classified as very good 65.3% patients, satisfactory 23% and poor in 9.2%. The accumulative risk for definition loss of the reconstructed fold was 11% in eight years.

Conclusion:

The technique presented in this article is a modification of already reported techniques and is easy and fast to perform, it adds no external scars so ensuring at the same time, natural inframammary fold definition and good reproduction of ptosis in medium to large breasts.

Level of Evidence:

Level IV, therapeutic study.     

An improved model for rat liver transplantation including arterial reconstruction and simplified microvascular suture techniques.

For experimental liver transplantation in the rat, the models that have been used most frequently do not include reconstruction of the arterial blood supply to the liver. In these procedures, specially developed cuff anastomoses rather than the conventional microvascular suture technique are used almost exclusively in the recipient operation, so that the anhepatic time is minimized. In this study the technical details of an improved rat model for orthotopic liver transplantation are described. During the donor operation in this experimental method, the liver is prepared with an arterial pedicle that includes the abdominal segment of the aorta, permitting perfusion in situ of the portal vein as well as the hepatic artery. The transplantation of the excised donor organ into the recipient site is carried out with simplified microvascular suture techniques and includes reconstruction of the arterial supply to the liver. Anastomosis of the bile duct is accomplished by choledocho-choledochostomy with a splint technique and supplemental suturing. For the entire procedure, magnifying glasses with 2- to 2.5-fold magnification are sufficient. When this technique has been mastered, the average duration of the anhepatic phase is about 20 min, well below the critical 30-min limit for survival of the experimental animals. As proficiency increased, the perioperative mortality was reduced to 9.2% (n = 130). With the combination of portal and arterial in situ flushing during the donor operation and the rearterialization of the transplant during the recipient operation, the clinical conditions can be approximated more closely than is possible when the transplanted rat liver is supplied only by the portal vein. Use of microvascular suture techniques, without cuff anastomoses, reduces the need for ex situ handling of the donor organ.     

Laparoscopic-assisted lumboperitoneal shunt: a simplified technique.

OBJECTIVES: Lumboperitoneal shunt has been advocated as a better alternative to ventriculoperitoneal shunt in communicating hydrocephalus. To minimize the morbidity of subcutaneous tunneling or an open abdominal wound, we developed a simplified technique for laparoscopy-assisted placement of lumboperitoneal shunts. METHODS: Patients deemed candidates for lumboperitoneal shunts underwent laparoscopy-assisted lumboperitoneal shunt placement. Using a Tuohy needle, the neurosurgeon obtains access to the lumbar subthecal space. Simultaneously, the laparoscopist obtains access to the peritoneal cavity with two 5-mm ports for the take down of the descending colon, clearing the way for the passage of the shunt passer from the back into the peritoneal cavity. RESULTS: Over the last 5 years, 45 patients have undergone laparoscopy-assisted lumboperitoneal shunt placement. Patients have been followed with neuropsychiatric examinations, imaging studies, and repeated neurological examinations. No complications related to the laparoscopy have occurred. Neurosurgical complications included postural headaches caused by overdrainage in 4 patients requiring laparoscopic modification of the shunt slit and in 1 patient with acquired Arnold-Chiari I malformation. CONCLUSION: Laparoscopy-assisted lumboperitoneal shunt offers many advantages over percutaneous ventriculoperitoneal or laparoscopic transabdominal lumboperitoneal shunts. The procedure can be performed in less than 30 minutes by any practicing laparoscopist.     

End-to-side portacaval shunt: a simplified technique.

A simplified technique of end-to-side portacaval shunt in the rat is described, consisting in using a microsuture with a looped end. By using this technique, combined with two-step portal vein venotomy, the portal vein and caval vein can be brought closer together in a single movement, with no need for a knot at the start of the shunt. As a result, this modified technique makes it easier and reduces the time required to perform the shunt, without any rise in associated mortality.     

An alternative technique for immediate breast reconstruction

Immediate reconstruction has demonstrated superior cosmesis compared with delayed reconstruction, however, unexpected final pathology may necessitate post mastectomy radiation. We describe an alternative technique for immediate breast reconstruction. Twelve patients underwent 14 skin-sparing mastectomies from July 2006 to December 2009. The skin-sparing mastectomies and sentinel node biopsies were performed through a periareolar incision. At the completion of the operation the incision was closed in a transverse fashion. No simultaneous reconstruction was performed. No drains were placed. After 3 days seroma developed, which maintained the integrity of the skin envelope and appearance of a breast. Nine patients (75%) had a contraindication to breast conservation. All patients were clinically node negative and 67 per cent were clinical stage 0. The majority (75%) experienced an adverse change from clinical stage to final pathologic stage. Four patients (33%) required postmastectomy radiation. The mean time from oncologic procedure to initial reconstruction procedure was 14 days. Two patients (17%) developed postoperative infections. This technique allows immediate reconstruction and avoids the fear of adverse final pathology indicating radiation to the reconstructed breast. In addition, it provides flexibility in scheduling for the surgeons and allows the patient to maintain the appearance of the breast.     

Needle biopsy of bone: a simplified technique.

By means of a slight modification of a commonly available needle, adequate amounts of bone for histopathology examination have been obtained from deep-seated bones, including vertebral bodies. Forty-one correct diagnoses were made in 51 consecutive cases in which the technique was used.     

Videothoracoscopy: improved technique and expanded indications.

Current videoendoscopic technology and percutaneous techniques of exposure and dissection have been successfully applied to abdominal surgery with favorable results. Application of this technology to our practice of thoracoscopy is the basis of this report. Videothoracoscopy has been performed in 39 patients for the following indications: chronic pleural effusion, interstitial lung disease, mediastinal lymphadenopathy in lung cancer, persistent air leak after decortication, mediastinal mass, recurrent spontaneous pneumothorax, hydropneumothorax with persistent air leak, and pleural-based mass. The technique we employ includes lateral decubitus positioning and double-lumen endotracheal intubation with ipsilateral lung collapse. The videoscope, retractors, and instruments are introduced through separate 10-mm incisions. Percutaneous manipulation of instruments and the videoscope is guided by images produced on television screens without dissection, and if resection is performed, the incision is enlarged to allow specimen retrieval. Procedures performed using this technique include pleural biopsy, partial pleurectomy, lysis of adhesions, lung biopsies, staging lymph node biopsy, lung nodule biopsy, pleural-based mass resection, and mediastinal mass biopsy and resection. This videoendoscopic technique greatly improves visualization of thoracic anatomy, facilitating thoracoscopy and enhancing exploration of the chest. It is preferred over conventional thoracoscopy and, in some patients, reduces the magnitude of operation by avoiding thoracotomy.     

The lower thoracic advancement technique in breast reconstruction

This technique, which uses local tissues, allows a modest supplementation of prethoracic skin coverage and creation of a stable, well-defined inframammary fold. With placement of a subpectoral implant, there is progressive expansion of the inferior and lateral skin coverage, resulting in progressively more natural ptotic shape. This expansion also allows subsequent increases in implant volume if appropriate. Advantages include good match of skin color and texture, confinement of donor site scarring to the relatively inconspicuous inframammary fold area, and relative ease of performance.     

A new simplified technique of arterial reconstruction in pediatric living-donor liver transplantation: A comparison with the classical technique

Background/Aim

Hepatic artery anastomosis (HAA) is the most important aspect of living donor liver transplantation (LDLT), and it is currently performed by a specialized microsurgeon using micro surgical techniques, with interrupted sutures and the aid of an operative microscope. To simplify the procedure, we studied a new, simpler technique performed by pediatric transplant surgeons with continuous sutures and the same 3.5 × magnification loupe used during other transplant procedures. The aim of this study was to compare these two hepatic artery reconstruction techniques in two pediatric LDLT series.

Methods

This study was initiated in January 2010 and finished in June 2013. In the first period, the arterial reconstruction was performed with an operating microscope and the classical technique of 9-0 separate sutures. In the second period, the arterial reconstruction was performed using a simpler technique, with surgical loupe and continuous 8-0 Prolene sutures. The incidences and outcomes of complications within the two periods were analyzed and compared.

Results

A total of 82 LDLTs were performed, 38 in the first period and 44 in the second period. There were no differences between the periods, except for the arterial ischemia time, which was lower in the second period.

Conclusion

Hepatic artery anastomosis can be safely performed with low complication rates by a pediatric transplant surgeon using continuous sutures with a 3.5 × magnifying loupe. This technique is simpler, less time consuming and simplifies the complex pediatric LDLT procedure.     

Testicular prosthesis in children: a simplified insertion technique.

A simplified technique for testicular prosthesis insertion in children is presented. The prosthetic testicle is inserted through an inguinal incision and slid into the scrotum. It is kept in position by closing the scrotal entrance with one suture applied through a small skin incision at the scrotal root. This technique has proved to be safe and reliable with regard to extrusions and migrations of the prostheses, as well as other complications.