Surg. Tech. Dev., Volume 2, Issue 1 (December 2012) – 10 articles

Vertical alveolar crest splitting and horizontal distraction of narrow alveolar crests is limited when rotating and low frequency oscillating tools are used due to large amounts of procedural bone loss and poor handling provisions. Aim of this study was to determine the safest osteotomy depth and to develop ultrasonic-surgery- tips to enable flapless vertical crest splitting and distraction of narrow alveolar crests of 2 mm or less. The safest osteotomy depth was determined on a cow-rib-model. To enable a flapless crest splitting and widening procedure, prototype-tips for the Piezotome-device were developed and tested against mechanical tools (widening screws and distractors) on cow-ribs, as well as their safe use in the hands of novicesurgeons on human cadaver heads. A minimum vertical osteotomy depth of 7–8 mm revealed the least fracture rates (3%). The use of the ultrasonic distraction tools showed the least risk of procedural failures (2%). Twentythree Piezotome-trainees performed the procedure with the developed tips on fresh full human cadaver skulls with a success rate of 100%. The results of this study suggest that, with the use of ultrasonic surgical devices, the indication for vertical crest-splitting can be narrowed down to a crest width of 2 mm and even less and that it can be performed flapless, thus leaving the physiological bone-periosteum system fully intact. Full article

The aim of this paper is to provide an analytical survey of the information available on the development of past and present surgical techniques, and to make projections for the future. For the purposes of this paper, the Past starts in the Neolithic period and ends in the 1800s. In this context, I have divided the Past into Prehistoric, Ancient and Middle Ages, and this period ends in the second half of the 19th century when the major obstacles to the further development of surgery, such as overcoming pain and infection, were removed. We will discuss the development of surgical techniques, and the obstacles and opportunities prevalent in these periods. In the context of this paper, the Present begins in 1867, when Louis Pasteur discovered microorganisms, and ends in the present day. There have been many important changes in the development of surgical techniques during this period, such as the transfer of surgery from the unsterile operating room to the modern hospital operating theater, the development of advanced and specialized surgical practices, such as transplants and laparoscopy, and minimally invasive surgical methods, robotic and Natural Orifice Transluminal Endoscopic Surgery. It is very difficult to foresee how surgical techniques will develop in the Future because of the unpredictable nature of technological progress. Therefore, in this paper, the forecast for the Future is limited to the next 50- 100 years and is a realistic calculation based on already existing technologies. In this context, the Future is divided into the development of surgical techniques that will develop in the near and distant future. It is anticipated that this overview will shed light on the historical perspective of surgical techniques and stimulate interest in their further development. Full article

In the excision of potentially malignant skin lesions, it is a surgeon’s duty to assist the pathologist in correctly orientating the specimen submitted for histological examination. The use of marker sutures by surgeons to indicate the orientation of resection specimens is commonplace, but we realized that the excision of a small, circular lesion with a neat, circular excision margin can be the undoing of even the most attentive surgeon, if the correct orientation is lost before the marker is placed. We present a simple extra step that a surgeon can take to ensure that his or her specimen’s orientation is preserved. Full article

Guided implant dentistry using computed tomographic (CT) scans, virtual planning software and mucosa-supported surgical templates is an upcoming technology with the potential for more predictable and less invasive implant placement. While generally associated with a flapless approach, soft tissue punching and removal may not be indicated if available width of keratinized mucosa is limited prior to implant surgery. Two techniques to preserve keratinized peri-implant mucosa (Punch Reposition Technique and Topical Flap Technique) are presented and indications outlined. Appreciation of soft tissue conditions as well as functional and esthetic consequences of mucosal deficiencies (mucosal-driven approach) is recommended to supplement bone- and prosthetic-driven considerations in guided oral implant placement (Trinity Approach). Full article

The Authors present a novel technique of immediate breast reconstruction with definite implants after mastectomy conserving the nipple- areola complex and, less frequently, in skin-sparing mastectomy. The increase of indications for both oncologic and prophylactic nipple-sparing mastectomy has induced the research for a single-stage technique that could replace the two-stage reconstruction with expanders and/or autogenous reconstructions with flaps. The new techniques introduce modifications of the pocket coverage for the implants occurring in two ways: (i) autologous adaptation of muscle-fascia-fat-skin layers, (ii) application of alloplastic materials as the meshes. A series of 124 immediate reconstructions were performed from 2008 to 2011 using a continuous composite pocket made of pectoralis maior and serratus anterior muscle above, and skin-fat flap below. The innovation is represented by an extended electrosurgical scoring of the lower pole of the mammary pocket at two levels. The first is the deep-fascia and muscle layer; the second is the superfiacial fascial system. This operative technique represents an advancement of a prior procedure described by the Authors in 1998. This preliminary study would primarily describe the technique step by step. Discussion debates about alternative techniques in terms of either surgical details of technique or cosmetic results are still to be reached. Full article

Sentinel lymph node biopsy (SLNB) is routinely used in the staging of invasive breast cancer. The aim of this study was to investigate the diagnostic accuracy of ultrasonography (US) compared to magnetic resonance imaging (MRI) in the pre-operative assessment of metastatic disease to the axilla in breast cancer patients at our community hospital. We retrospectively reviewed a prospectively collected database of 277 patients seen at our breast center from 2009 to 2010. Patients with invasive breast cancer were then evaluated for axillary metastasis. Lymph nodes were sampled using fine needle aspiration (FNAB) or core biopsy. Histopathology of the sentinel lymph nodes (SLN) or results of the axillary dissection were compared to US or MRI results. A total of 228 patients had invasive breast cancer. In these patients, 122 lymph nodes were sampled. Pathology proven metastases to axillary lymph nodes were found in 76 cases. Accuracy and sensitivity were higher in US than MRI in detecting metastatic disease to the axilla (70.2%, 84.6%, p < 0.001 and 60.0%, 52.6%, p < 0.1, respectively). US was more accurate than MRI at detecting metastatic breast cancer in the axilla in our community hospital. Axillary US should be a routine part of assessment of breast cancer patients. Full article

Preservation of olfactory function during anterior skull base surgery has been previously described. However, its feasibility during oncological resection remains undefined. The aim of this study was to clarify the feasibility of preserving olfactory function in select patients undergoing oncological anterior skull base resection via endonasal endoscopic approach. This is a retrospective case series study. Postoperatively, all patients underwent a standardized smell identification test (Sensonics Inc., Haddon, NJ, USA). From January 2002 to December 2009, we attempted to preserve olfactory function in 9 patients who required an endoscopic resection involving the anterior skull base for treatment of various malignancies presenting unilateral extension. These included: esthesioneuroblastoma (n = 6), squamous cell carcinoma (n = 1), adenocarcinoma (n = 1) and hemangiopericytoma (n = 1). In 7 patients, resection included a unilateral endoscopic craniectomy with preservation of the contralateral middle and superior turbinates. Two patients underwent resection of the entire lateral nasal wall and the olfactory epithelium as the superior limit of tumor resection. Six patients received adjuvant radiotherapy. Postoperatively, olfaction was documented in 7 patients (3 normosmic, 4 microsmic). All patients are free of recurrence at the original site at a mean follow-up period of 55.7 months (range 21–101 months). One patient with an esthesioneuroblastoma developed a cervical lymph node recurrence four years after surgery. In selected cases, it is feasible to preserve olfactory function without apparent compromise of oncological outcomes. The success rate depends largely on the extent of the resection, which, in turn, is dictated, by the extent of the tumor. Full article

Repair of abdominal wall defects in the presence of contamination or infection is a significant problem. The loss of tissue warrants enforcement of the abdominal wall, preferably by autologous material. However, autologous repair often requires extensive surgery. This paper presents a review of available literature of placement of an acellular human dermis to repair an abdominal fascia defect, in contaminated as well as in non-contaminated surgical fields. It is illustrated with a case report that describes the successful reconstruction of an infected abdominal wall defect with a human acellular dermis allograft. A systematic literature review was undertaken with searches performed in the Pubmed and Cochrane databases for the period up till March 2009, using the search terms Alloderm [Substance Name], Hernia [Mesh] and the key words acellular dermis, acellular dermal matrix, human acellular dermal allograft and abdominal wall defect. To assess methodological quality, each article was subjected to a modification of the methodological index for non-randomized studies (MINORS) according to Slim et al. Two items from the original index were not included because none of the studies selected had an unbiased assessment of the study end points and in none of the studies was a prospective calculation of the study size performed. Seventeen studies were included in the review. Data were extracted regarding study design, number of patients, surgical technique, followup period, contaminated or non-contaminated area of the fascia defect, mortality and morbidity (hemorrhage, seroma, wound dehiscence, infection) of the operative procedure, the longterm results (removal of the graft, reherniation and bulging) and level of evidencey. A total of 169 short-term complications and 151 longterm complications occurred after 643 surgical procedures reconstructing both contaminated and clean abdominal wall defects by implantation of an HADA. Human acellular dermal allograft seems to be a good alternative for autologous repair of contaminated or infected abdominal wall defects. Full article

A case of 5-year-old boy with a left congenital undescended scapula graded Cavendish III was consulted in our unit and operated successfully with the Woodward technique. It was the first case treated by this procedure for the past 10 years, in the Pediatric Surgical Unit of the Yaounde Gyneco-Obstetric and Pediatric Hospital (Cameroon). The Woodward procedure permitted to obtain a good functional and cosmetic result. Full article