Surgeries

Over the past few decades, surgeon training has changed dramatically. Surgical skills are now taught in a surgical skills laboratory instead of the operating room. Simulation-based training helps medical students improve their skills, but it has not revolutionized clinical education. One critical barrier to reaching such a desired goal is the lack of reliable, robust, and objective methods for assessing the effectiveness of training sessions and the development of students. In this paper, we will develop a new comparative analysis approach that employs network models as the central concept in establishing a new assessment tool for the evaluation of the surgical skills of trainees as well as the training processes. The model is populated using participants electromyography data while performing a simulation task. Furthermore, using NASA Task Load Index score, participants’ subjective overload levels are analyzed to examine the impact of participants’ perception of their mental demand, physical demand, temporal demand, performance, effort, and frustration on how participants perform each simulation task. Obtained results indicate that the proposed approach enables us to extract useful information from the raw data and provides an objective method for assessment the of surgical simulation tasks and how the participants’ perception of task impacts their performance. Full article

We report a patient who was referred to the emergency room with pulmonary complaints and where a computed tomography (CT) scan showed an unexpected 12.6 cm nail in the thorax penetrating part of the left pulmonary upper lobe, the left pulmonary artery, the left main bronchus, and the descending aorta, which had been in situ for at least three days. The quickly deteriorating patient had to be transferred to a tertiary academic hospital where the nail was successfully surgically removed. The comprehensive description of this unique case with a discussion of the critical decision moments could render insights into the management of challenging trauma cases. Full article

Introduction with Aim: Postoperative respiratory depression can complicate a patient’s recovery after surgery. A predictive score (PRODIGY) was recently proposed to evaluate the risk of opioid-induced postoperative respiratory depression. For the first time, we applied this score to a cohort of patients receiving bariatric surgery, stratified by Obstructive Sleep Apnea (OSA) status. In addition, we recorded continuous postoperative capnography to evaluate respiratory depression and apnea episodes (Respiratory Events, RE). Materials and Methods: The present study was approved by our IRB and comprised continuous surveillance of respiratory variables during postoperative recovery (in PACU) after robotic bariatric surgery. We utilized continuous capnography and pulse oximetry (Capnostream 35, Medtronic Inc., and Profox Respiratory Oximetry software). Preoperative preparation included OSA evaluation for all bariatric patients, additional sleep studies for severe OSA grades, and evaluation of risk for respiratory depression (low, intermediate, or high) using the published PRODIGY score. In addition, we evaluated patients by OSA status. All patients received multimodal intraoperative non-opioid anesthesia from the same team. After surgery, all patients received continuous respiratory surveillance in PACU (average duration exceeding 140 min). Respiratory depression events were scored using a modified list of the five standard published categories. Events were measured according to analysis of continuously recorded tracing of the compiled respiratory variables by observers kept blind from the study patient’s group. Results: Of the 80 patients evaluated (18 male), 56 had obstructive sleep apnea and were using CPAP at home (OSA); 24 did not. OSA patients received CPAP via an oronasal mask or a nasal pillow pressure support immediately after arriving in PACU, utilizing their at-home settings. We encountered 115 respiratory depression events across 48 patients. The most frequent respiratory event recorded was a transient desaturation (as low as 85%), which usually lasted 20–30 sec and resolved spontaneously in 3 to 5 min; most episodes followed small boluses of IV opioid analgesia administered during recovery, on demand. All episodes resolved spontaneously without any nursing or medical intervention. OSA patients had significantly more events than non-OSA patients (1.84 (1.78–1.9) mean events vs. 0.50 (0.43–0.57) for non-OSA, p = 0.0002). The level of PRODIGY score (low, intermediate, or high), instead, was not predictive of the number of events when we treated this variable as continuous (p = 0.39) or categorical (high vs. low, p = 0.65, and intermediate vs. low, p = 0.17). Conclusions: We attribute these novel results, showing a lack of respiratory events requiring intervention, to opioid-free anesthesia, early CPAP utilization, and head-up positioning on admission to PACU. Furthermore, all these patients had light postoperative narcotic requirements. Finally, an elevated PRODIGY score in our patients did not sufficiently predict respiratory events, but OSA status alone did. Key Points Summary: We investigated the incidence of Respiratory Events (RE) in Obstructive Sleep Apnea patients after surgery (56 patients) and compared them to similar patients without OSA (24 patients). All patients received identical robotic-assisted surgery and low- or no-opiate anesthesia. Patients were pre-screened with the standard published PRODIGY scores and were monitored after PACU arrival with continuous oximetry and capnography (Capnostream 35 and Profox analysis). OSA patients showed more RE than non-OSA (1.8 vs. 0.5, p = −0.0002). However, patients with elevated PRODIGY scores did not develop more frequent RE compared to patients with low scores. We attribute these novel results to opioid-sparing anesthesia/analgesia and immediate CPAP utilization on admission to PACU. Full article

Dunbar syndrome is caused by the compression of the celiac artery by the median arcuate ligament (MAL) and the diaphragmatic crura, presenting with abdominal pain. The treatment is surgical, with the aim of dissecting and separating the diaphragmatic crura from the celiac axis, restoring blood flow in the celiac trunk. We propose the use of transesophageal echocardiography to measure the peak systolic velocity in the celiac trunk and to evaluate, in real time, the efficacy of the surgery during MAL resection. Two clinical cases with practical implications are reported. In one of these, the ultrasound exam was useful in providing an intraoperative confirmation of the outcome of the resection. Full article

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare variant of mullerian duct anomalies characterized by the triad of uterine didelphys, obstructed hemivagina and ipsilateral renal agenesis. We report two cases of HWW syndrome in young women with abdominal pain. This diagnosis can easily be missed if a clinician is not aware of the syndrome. In one case, the computed tomography image of obstructed hemivagina with hematocolpos was initially mistaken for a cystic tumor of adnexa by the radiologist; in the other case, correct diagnosis was missed for years despite numerous visits to different hospitals due to lack of awareness of the syndrome. Full article

The general improvement in life expectancy and standard of living makes it easier for patients to get access to routine medical exams and is anticipated to increase the prevalence of several degenerative joint illnesses. In addition, it is anticipated that their incidence will increase both nationally and internationally, which will raise the demand for novel and long-lasting implantable devices in the field of orthopedics. The current review’s goals are to define what constitutes a biocompatible orthopedic implant in terms of in vitro biocompatibility testing and to clarify important concepts and definitions that are already in use. The demand for materials and implants made of various tissues is now increasing, and the ongoing advancement of in vitro cell culture studies is a reliable practical tool for examining the biocompatibility of potential implantable materials. In vitro biocompatibility research has been reduced and, in most cases, diminished to laboratory studies that no longer or drastically reduce animal sacrifice as a response to the well-known three “Rs” (“reduction”, “refinement”, and “replacement”) introduced to literature by English academics in the 1960s. As technology advances at an astounding rate, a new generation of gene-activating biomaterials tailored for specific people and disease conditions might emerge in the near future. Full article

Treatment of basilar artery trunk aneurysms is still challenging today, although numerous approaches and modalities of treatment exist. The authors present a case of a patient with a partially thrombosed, ruptured basilar trunk artery aneurysm successfully treated by clipping occlusion of the rupture point and multilayered wrapping of the aneurysmal dome. A 49-year-old man presented to our emergency room with a chief complaint of altered mental status. The patient was diagnosed with subarachnoid hemorrhage (SAH). No apparent bleeding point was identified on initial 3-dimension computerized tomography (CT) angiography and digital subtraction angiography (DSA). Follow-up DSA revealed a partially thrombosed saccular aneurysm emerging from the basilar trunk. We decided to treat the aneurysm surgically with partial clipping including the bleb and wrapping via the anterior transpetrosal approach. The surgery was performed successfully without any complications, and the residual blood flow within the aneurysm diminished remarkably over time. Although direct clipping and wrapping for basilar trunk artery aneurysms is one of the most challenging operations, it is a highly effective treatment for complex aneurysms, especially if other treatments are not available. Full article

Adjacent segment problems after cervical spine instrumentation are widely reported. They can range from asymptomatic adjacent segment degeneration (ASD) noted on radiographs to symptomatic adjacent segment disease and even instability. While ASD following anterior instrumentation is well studied, there is a paucity of literature on ASD following posterior instrumentation. We intended to identify the risk factors associated with ASD following posterior instrumentation, focusing on pre-operative and surgical parameters. Eighty-seven patients who underwent posterior instrumentation of the cervical spine were recruited. Clinical and radiological examination was performed preoperatively and up to 24 months postoperatively. The collected data included patient demographics, indication for surgery, sagittal parameters (cervical lordosis, C2–7 sagittal-vertical axis), technique of surgery, number of levels instrumented and fused, number of levels decompressed, and the level at which the instrumentation ended. Based on postoperative evaluation, ASD was found in 29.9% of the patients, of which, one patient was symptomatic and required reoperation. Even though, according to our univariate analysis, reduced pre-operative cervical lordosis and the indication of degenerative spondylosis seemed to significantly influence the occurrence of ASD, multivariate regression analysis did not identify any independent risk factors. We also noted that, even though patients may develop ASD after the instrumented fusion of the cervical spine, this may not necessarily develop into symptomatic adjacent segment disease requiring revision surgery. Full article

Laparoscopic surgery (LS) is a minimally invasive technique that offers many advantages over traditional open surgery: it reduces trauma, scarring, and shortens recovery time. However, an important limitation is the loss of tactile sensations. Although some progress has been made in robotic-assisted minimally invasive surgery (RMIS) setups, RMIS is still not widely accessible. This review aims to identify which tactile display technologies have been proposed and experimentally validated for the restoration of tactile sensations during conventional laparoscopic surgical tasks. We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We identified relevant articles published over the past 10 years through a search on Web of science, Scopus, IEEE Xplore Digital, and PubMed repositories. A total of 143 articles met the inclusion criteria and 24 were included in the final review. From the reviewed articles, we classified the proposed tactile displays into two categories based on the use of skin contact: (i) skin tactile displays, which include vibrotactile, skin-indentation, and grip-feedback devices, and (ii) non-contact tactile displays based on visualization tools. This survey aims to contribute to further research in the area of tactile displays for laparoscopic surgery by providing a better understanding of the current state of the art and identifying the remaining challenges. Full article

Here, we report a new surgical technique designed to increase filtration volume and reduce intraocular pressure (IOP) in glaucoma and its one-year outcome. Two tubes were created from a single Baerveldt glaucoma implant (BI) by folding the tube in a U-shape and incising only the outer edge of the stretched loop tip. The tubes were placed into the vitreous cavity via the pars plana through a long scleral tunnel, without a scleral valve or graft patch. Twenty eyes of 18 patients with neovascular glaucoma were included. This technique was performed in 10 eyes of 10 patients (double group), and outcomes were compared to 10 eyes of eight patients in which a single tube BI was inserted (single group). The primary outcome measures included IOP, supplemental medical therapy score (SMTS), and intraoperative and postoperative complications before and after surgery at 12 months. The mean IOP (SMTS) were 32.0 ± 11.33 mmHg (4.1) in the double group and 29.7 ± 6.31 mmHg (5.7) in the single group, preoperatively reduced to 11.8 ± 2.70 mmHg (0.2) (63% reduction, p < 0.004) and 14.2 ± 4.05 mmHg (1.1) (52% reduction, p < 0.002) after 12 months, respectively. SMTS showed 95% (p = 0.005) and 89% (p = 0.005) reductions, respectively. Although there was no significant difference in IOP between the two groups at 12 months (p = 0.16), there were significant differences in the SMTS between the two groups before, and 6 and 12 months after, surgery (p = 0.01, 0.04 and 0.04, respectively). A reduction in the SMTS suggests that increasing filtration volume by placing two tubes has the potential to further reduce IOP as compared with a single tube. Full article

Background: Ventricular peritoneal shunting (VPS) is a frequent procedure in neurosurgery, unfortunately still burdened with a significant rate of complications. The frontal Kocher’s point is the most frequently used landmark for ventricular puncture. Keen’s point (posterior parietal approach) seems to be a valid alternative. We report a newly described access to the lateral ventricle located in posterior temporal area and the results of a large series of adult patients. Methods: Retrospective analysis of a series of 188 cases of VPS performed with this approach. Results: Mean surgical time was 51.5 +/− 13.1 min (range 25–90 min). Twenty-one patients (11.2%) were subjected to revision surgery: eight cases (4.3%) for displacement or malfunction of ventricular catheter, eight cases (4.3%) for abdominal issues, three cases (1.6%) for hardware failure, and two cases (1.1%) for infection. Optimal catheter placement was reached in 90.1%. Conclusions: The modified Keen’s point approach seems to be safe, technically feasible, and reproducible, showing some potential advantages such as short surgical time, precision in ventricular catheter placement, and short tunneling tract. The need for surgical revision is similar to that reported in the literature, while the rate of catheter malpositioning and infections seems to be low; hemorrhages around catheter and seizures were not reported. Full article

The atrophic edentulous maxilla is demanding for dental implant placement because of extensive resorption of the alveolar ridge after teeth loss and, consequently, the proximity of the anatomical structures, nasal cavity, and maxillary sinus. Treatment options are short implants, guided bone regeneration, onlay grafts, Le Fort I osteotomy with interpositional bone grafting, distraction osteogenesis, or nasal floor elevation. Nasal floor elevation is a method of augmentation of premaxilla by raising the base of the nose. The aim of this case report is to evaluate the success of implants placed after nasal floor elevation. A 75-year-old female patient came to the Clinical Department of Oral Surgery, University Hospital Centre Zagreb, unsatisfied with her complete removable denture. Clinical and radiological examination revealed severe maxillary alveolar ridge atrophy. Nasal floor elevation was made under local anesthesia through aperture piriformis and lateral window in the distal part. After eight months, four implants were placed and, after period of osseointegration, a bar-retained implant overdenture was made. This case report shows that nasal floor augmentation can be considered among the surgical techniques to allow implant-supported rehabilitation of the atrophic anterior maxilla. Full article

Background: New technologies and techniques allow us to offer better solutions for patients’ needs. Specifically, guided surgery is usually flapless, and the resulting prosthetic rehabilitation often includes immediate loading. Thus, bleeding risk is controlled, and more comfortable prosthetic procedures are performed. Guided surgery decreases surgical risks and is less invasive. The aim of this article is to present a case of guided osteotomy for bone biopsy and implant placement. Methods: CBCT was performed for the patient’s bone examination, an optical scanner was used for intra-oral images, and surgical certified software was applied for the osteotomy planning and the surgeon’s guide realization. Case report: The patient’s question is about left maxilla prosthetic rehabilitation. During the oral cavity and X-ray examination, a radiopacity with a feathered edge was found; in order to detect the finding, a CBCT was performed, and the surgery was planned. A bone biopsy was performed simultaneously with the implant’s placement through a drill guide. The specimen sent for histological exam showed osteosclerosis. Conclusions: It is the opinion of the authors that by involving and combining close collaboration and communication, several professional specializations (clinicians and radiologists) can improve the treatments for better patient care. Full article

Background: Prehabilitation is gaining increasing interest and shows promising effects on short- and long-term outcomes among patients undergoing major surgery. The effect of multimodal, interdisciplinary prehabilitation has not yet been studied in patients with severe heart failure scheduled for the implantation of a left-ventricular assist device (LVAD). Methods: This randomized controlled multi-center study evaluates the effect of preoperative combined optimization of nutritional and functional status. Patients in the intervention group are prescribed daily in-bed cycling and oral nutrition supplements (ONS) from study inclusion until the day before LVAD-implantation. Patients in the control group receive standard of care treatment. The primary outcomes for the pilot study that involves 48 patients are safety (occurrence of adverse events), efficacy (group separation regarding the intake of macronutrients), feasibility of the trial protocol (compliance (percentage of received interventions) and confirmation of recruitment rates. Secondary outcomes include longitudinal measurements of muscle mass, muscle strength, physical function and quality of life, next to traditional clinical outcomes (30-day mortality, hospital and ICU length of stay, duration of mechanical ventilation and number of complications and infections). If the pilot study is successful, a larger confirmatory, international multicenter study is warranted. Full article

Objective: Worldwide cervical cancer is the fourth most common cancer and is also the fourth leading cause of death among women, after breast cancer, colorectal cancer, and lung cancer. The aim of this study is to investigate the long-term oncological safety of laparoscopic treatment without the use of a uterine manipulator for patients with early stage cervical cancer. Materials and methods: A single-center retrospective study was conducted at the Department of Obstetrics and Gynecology of ARNAS Garibaldi Nesima on patients surgically treated for early cervical cancer from 2014 to 2017. Inclusion criteria included squamous or adenosquamous histotype, FIGO stage from Ia1 to Ib2, cancer size < 4 cm, ECOG status 0–1, and negative serum beta-HCG. The patients were divided into two groups: treatment with and without an intra-uterine manipulator. Results: Seventy patients were identified, but only thirty-one met the inclusion criteria and were enrolled. All patients underwent surgery: three patients with the uterine manipulator, twenty-eight without. Among the thirty-one patients enrolled, twelve women had cancer in situ (IA1), nineteen had an early stage cervical cancer, in particular two cases of cervical cancer stage IA2, ten cases of cervical cancer stage IB1, and seven cases of cervical cancer stage IB2, according to the FIGO classification. At follow-up, three cases of recurrence occurred, but the uterine manipulator was not used. Conclusion: After five years of follow-up, recurrence rates in patients treated with minimally invasive surgery are about 10%, but the use of a uterine manipulator is not related to a higher level of recurrence rates. Full article

Extended tracheal resection after neoadjuvant chemotherapy is rarely described in patients with tracheal cancer. Controversies still exist among surgeons about the length of tracheal resectability and possible harmful anastomotic complications. Different vascularized tissue flaps can be used to protect the anastomotic suture line. We reported a 67-year-old patient with middle tracheal squamous cell carcinoma treated by induction chemotherapy followed by a successful extended tracheal resection. The anastomosis was covered by a reversed thymic fat pad flap to prevent the erosion of adjacent brachiocephalic vessels. Postoperative concurrent chemoradiation did not threaten the integrity of the suture line. Careful tracheal dissection and accurate release manoeuvres are mandatory to achieve a tension-limited anastomosis. Extended tracheal resection may be safely performed after induction chemotherapy, with excellent long-term outcomes. A thymic fat flap seems to be beneficial to suture-line healing. Full article

Selective Nerve Root Block (SNRB) is a precise local injection technique that can be utilised to target a particular inflamed nerve root causing lumbar radiculopathy for both diagnostic and therapeutic purposes. Usually, for SNRB to be therapeutic, a combination of a local anaesthetic agent and a steroid is injected under imaging guidance, whereas for diagnostic purposes, just the local anaesthetic agent is injected. While the ideal treatment strategy is to relieve the nerve root from its compressing pathology, local injection of steroids targeted at the affected nerve root can also be attempted to reduce inflammation and thus achieve pain relief. Although the general principle for administering an SNRB remains largely the same across the field, there are differences in techniques depending on the region and level of the spine that is targeted. Moreover, drug combinations utilised by clinicians vary based on preference. The proven benefits of SNRBs largely outweigh their risks, and the procedure is deemed safe and well tolerated in a majority of patients. In this narrative, we explore the existing literature and seek to provide a comprehensive understanding of SNRB as a treatment for lumbar radiculopathy, its indications, techniques, outcomes, and complications. Full article

The COVID-19 pandemic has been a great challenge, especially for families. We aimed to analyze the impact of the pandemic on childcare for and the work–family balance of pediatric surgeons in Germany. An anonymized questionnaire on the working and familial situation before and during the COVID-19 pandemic was sent to the members of the German Society of Pediatric Surgery and trainees in pediatric surgery (April–July 2021). One-hundred-fifty-three participants (59% female) completed the questionnaire. A total of 16% of the males and 62% of the females worked part-time. Most (68%) had underage children. During the COVID-19 pandemic, 36% reported a decrease in patients and interventions, and 55% reported an increase in the organizational work-related burden. Childcare for underage children during lockdown was organized mainly with the help of institutional emergency childcare (45%), staying home (34%), one parent working from a home office (33%), or staying home by themselves (34%). Before the lockdown, 54% reported a good work–family balance. During the lockdown, this worsened by 42%. Most of the families had to organize themselves. Different means such as a home office, flexible working hours, and different models for childcare can help to improve the situation. Full article