Surgical Techniques Development doi: 10.3390/std15040039

Authors: Caroline Deutschmann Soeren Stoeckel Christel Trifone Till Schoenherr Robert Luck Yusef Moulla

Background: Evidence on Versius-assisted oesophagectomy remains limited. This retrospective single-centre case series describes the early implementation and outcomes of a fully minimally invasive Ivor–Lewis procedure comprising a laparoscopic abdominal phase and a Versius-assisted thoracic phase. Methods: A retrospective analysis was performed on prospectively collected data from 34 consecutive patients who underwent the RAMIE procedure using the Versius Surgical System at Klinikum Chemnitz between September 2024 and July 2025. The surgical technique consisted of a laparoscopic abdominal phase followed by a robotic thoracic phase with intrathoracic circular stapled anastomosis. The primary aim was to assess the safety and feasibility of using the Versius Surgical System in esophageal surgery. Results: The mean operative time was 329 min (range: 245–416), and the mean docking time was 11 min (range: 6–27). No conversions to laparoscopic or open procedures occurred (0%). R0 resection was achieved in 91.2% of patients. The median lymph node harvest was 28 (range: 15–44). The anastomotic leak rate was 8.8%, with no associated mortality. No deaths occurred within 90 days after surgery. Conclusions: In this initial single-centre series, the planned robotic Versius-assisted approach was completed in all patients. The observed perioperative and pathological outcomes provide preliminary descriptive evidence to support further prospective evaluation. They do not establish comparative safety, efficacy, or oncological equivalence.

Surgical Techniques Development doi: 10.3390/std15040038

Authors: Florina Popa Rãzvan Adam Corina-Cecilia Manole-Pãlivan Cristina Stanescu Cosmin Moldovan

Background/Objectives: Upper-limb prosthetic performance depends not only on the mechanical and computational capabilities of the device but also on the quality, selectivity, stability, and accessibility of biological signals available within the residual limb. Methods: A structured narrative search of PubMed/MEDLINE, Scopus, Web of Science Core Collection, IEEE Xplore, targeted Google Scholar searches, and citation chaining was conducted through 11 August 2026. The final synthesis included 111 publications and examined muscle architecture, intervening soft tissues, nerve management, electromyographic control, rehabilitation, surgically created interfaces, implanted sensing, osseointegration, and sensory feedback. Results: Particular attention is given to an earlier developmental research line involving myoelectric acquisition, personalized training, residual-muscle redistribution, fascial signal transmission, nerve mapping, and implantable neural sensing, which is critically contextualized against independent contemporary evidence. Exploratory residual-limb surgical approaches are distinguished from interventions with stronger clinical support. Conclusions: On this basis, we propose the concept of interface-conscious upper-limb amputation: the preservation, organization, accessibility, training, and longitudinal adaptability of the biological structures required for present and future prosthetic control. This framework is not a validated surgical protocol, but a clinically oriented synthesis intended to connect amputation surgery with rehabilitation, neuroprosthetics, and long-term technological evolution.

Surgical Techniques Development doi: 10.3390/std15040037

Authors: Paolo Magagna Domenico Mangino James Reese Parada Lorenzana Elenilson Mauricio Mejía Melgar Francisco José Gamero Alfaro Guillermo Rodríguez Funes Kevin Ariel Rivas Campos Vélveth Beborly Jeannice Duque García Lorenzo Mingozzi Yuvraj Juttla Byron Pontón Guajala Serhii Kuchma Juan David Romero Roger Yoel Conde Moncada Pietro Permon Said Ismail Bariș Faizus Sazzad

Background: Access to cardiovascular surgical simulation remains limited by cost, logistical complexity, and dependence on dedicated facilities. MAGA SURGICAL SIMULATOR 2.0 was developed as a portable, modular, suitcase-based platform combining open and endoscopic training with active fluid circulation and immediate leakage assessment. Methods: The simulator supports multiple vascular anastomotic configurations, purse-string suturing, and aortic cannulation. After unrestricted use of the open configuration, an anonymous international questionnaire assessed feasibility, usability, realism, perceived educational value, and perceived transferability using 5-point Likert scales and open-ended questions. A subsequent exploratory follow-up assessed continued use and self-reported changes over time. Results: Twenty-two participants from eight countries completed the initial questionnaire: 14 residents, five attending surgeons, two medical students, and one junior doctor. All respondents considered the simulator useful, effective for reproducing surgical gestures, and valuable for practicing with active circulation. Mean scores were 4.71 ± 0.64 for ease of use and 4.55 ± 0.60 for perceived realism. Self-reported improvement scores were 4.77 ± 0.69 for instrument handling and 4.64 ± 0.79 for manual dexterity. Six of 22 initial participants (27.3%) completed the exploratory follow-up. Four reported regular continued use, and five reported shorter completion times; recorded rather than perceived task times were available for only two respondents. Recurrent strengths were portability, independent practice, real-time leakage detection, and immediate corrective feedback. Conclusions: MAGA SURGICAL SIMULATOR 2.0 appears feasible, usable, and acceptable across heterogeneous international settings. The findings support further prospective validation using standardized tasks and objective performance measures; they do not establish clinical effectiveness.

Surgical Techniques Development doi: 10.3390/std15040036

Authors: Alfio Luca Costa Gloria Fanton Franco Bassetto Vincenzo Vindigni

Background/Objectives: Medial thighplasty after massive weight loss is associated with wound dehiscence, seroma, prolonged edema, and potential alterations in lower-limb lymphatic drainage. Conventional refinements rely largely on the surgeon’s understanding of distorted lymphatic anatomy. We describe a simple adjunct using preoperative intradermal methylene blue injection to visualize linear structures morphologically consistent with superficial lymphatic pathways during medial thigh lift. Methods: After standard preoperative markings, dilute methylene blue was injected intradermally along the planned medial thigh resection pattern after induction of anesthesia and before skin preparation. During flap elevation, discrete blue linear channels were identified within the superficial adipose layer. Resection was performed down to, but not through, the plane of these channels, which were preserved on the residual bed and avoided during suspension suturing and liposuction. Between December 2021 and December 2022, the technique was applied in 10 non-consecutive female patients after massive weight loss. Results: Blue-stained linear channels were identified in all 10 selected cases. No patient required reoperation or readmission. Minor wound-healing complications occurred in 5 of 10 patients and were managed on an outpatient basis. Conclusions: Intradermal methylene blue injection permits intraoperative identification of stained linear channels during medial thighplasty and can be incorporated without specialized equipment. Their lymphatic identity and postoperative patency were not confirmed by histology or functional imaging. In the absence of a control group and inferential analysis, any lymphatic-sparing effect remains unproven and requires prospective controlled evaluation with objective lymphatic outcomes.

Surgical Techniques Development doi: 10.3390/std15030035

Authors: Shai Hoffman Moshe Argaman Rotem Horowitz Narmin Zoabi Adela Perlmuter Aviad Gravetz Eviatar Nesher Fahim Kanani

Background: The right renal vein is about half the length of the right renal artery and is shortened further by endovascular stapling at laparoscopic donor nephrectomy. Right-sided living-donor grafts carry roughly twice the adjusted risk of delayed graft function and of early graft loss, a penalty absent from deceased donation, where the inferior vena cava accompanies the graft. The deficit is one of venous length, not of the organ; extension is the remedy, and no guideline specifies how the conduit should be obtained. Methods and cases: Three consecutive recipients of right living-donor kidneys had the renal vein extended with a deceased-donor iliac vein. Conduits were recovered at multiorgan retrieval from ABO-identical or ABO-compatible donors, immersed in University of Wisconsin solution at 4 °C, and used within seven days; elective right donor nephrectomy was booked to follow a suitable retrieval within that window. Extension was an end-to-end back-table anastomosis with continuous 5-0 or 6-0 polypropylene, converting a short-vein implantation into a routine end-to-side anastomosis to the external iliac vein. All three grafts functioned immediately, without venous thrombosis, technical graft loss, or delayed graft function; the last serum creatinine was 0.91, 1.22, and 1.42 mg/dL. Conclusions. A calibre- and ABO-matched deceased-donor iliac vein, held in University of Wisconsin solution at 4 °C and used within seven days, makes venous extension a scheduled step of an elective right living-donor operation and requires no cryopreservation infrastructure. Where a donor’s safety mandates right nephrectomy, a short right renal vein need not preclude donation. Three cases establish feasibility; the low thrombotic risk of venous extension rests on published series rather than on this report.

Surgical Techniques Development doi: 10.3390/std15030034

Authors: Clara García-Rayo Natalia Miranda Utrera Silvia Juste Álvarez Carlos González Albarrán Carmelo Loinaz Segurola José Antonio González Fajardo Jorge Calvo Pulido Alfredo Rodríguez Antolín Ángel Tejido Sánchez

Background: Inferior vena cava (IVC) leiomyosarcoma is a rare vascular malignancy for which complete surgical resection remains the only potentially curative treatment. Surgical management is technically demanding, particularly when the tumor involves the renal veins and retrohepatic IVC, requiring complex vascular reconstruction while preserving renal function. Case Presentation: We report the case of a 60-year-old woman with a localized high-grade IVC leiomyosarcoma involving the retrohepatic cava and both renal vein ostia, with cranial intraluminal extension toward the right atrium. Following multidisciplinary evaluation, the patient underwent en bloc tumor resection with reconstruction of the IVC using a 20mm ringed polytetrafluoroethylene (PTFE) graft. Left renal venous drainage was restored through prosthetic reconstruction using a tubular pericardial conduit anastomosed to the prosthetic graft, while renal function on the right side was preserved by renal autotransplantation into the right iliac fossa. Histopathological examination confirmed a high-grade leiomyosarcoma with negative surgical margins (R0 resection). Adjuvant chemotherapy with doxorubicin and dacarbazine was initiated but discontinued after two cycles because of cardiotoxicity. Fourteen months after surgery, the patient remains disease-free with preserved renal function. Conclusions: Radical resection combined with tailored vascular reconstruction remains the cornerstone of treatment for localized IVC leiomyosarcoma. When the renal veins are involved, combining prosthetic caval reconstruction with renal autotransplantation may represent a safe and feasible strategy to preserve renal function while achieving complete oncological resection.

Surgical Techniques Development doi: 10.3390/std15030033

Authors: Richard J. Parkinson Ralph J. Mobbs Christopher Huang William C. H. Parr

Background/Objectives: The integration of three-dimensional (3D) printing and virtual surgical planning (VSP) has introduced a new standard in spinal surgery, enabling highly individualised preoperative preparation and intraoperative execution. Methods: By virtually reconstructing patient anatomy, surgeons can identify critical vascular corridors, analyse endplate morphology, determine optimal interbody cage geometry for the best anatomical fit, and predefine screw trajectories and entry points with exceptional accuracy. This level of planning reduces intraoperative uncertainty and minimises the risk of implant malposition, particularly in anatomically complex scenarios, such as the current case report. Quantitative assessment of alignment correction can also be performed preoperatively, allowing the surgeon to model and predict postoperative spinal balance with greater precision. This technology is particularly advantageous in congenital spinal anomalies, such as hemivertebrae, where orientation can be challenging and anatomical landmarks are often distorted or partially obscured. Results: We report the application of 3D-printed patient-specific implants (PSIs) in conjunction with VSP to perform a single-level, standalone anterior lumbar interbody fusion (ALIF) for the treatment of congenital scoliosis due to a left hemivertebra, associated with progressive left L5/S1 foraminal stenosis. Conclusion: This is the first case of a standalone ALIF for this indication. The patient presented with severe left L5 radicular pain and motor–sensory radiculopathy. The use of a PSI facilitated precise reconstruction of the spinal column, optimised implant fit and enhanced surgical accuracy in this technically complex case.

Surgical Techniques Development doi: 10.3390/std15030032

Authors: Motoyasu Tabuchi Teppei Tokumaru Sunao Uemura Shuta Tamura Takehiro Okabayashi

Background and Aims: Benign hepaticojejunostomy stricture (HJS) remains a challenging long-term complication after major hepatobiliary surgery. Although advanced endoscopic and interventional modalities have improved clinical outcomes, successful management is heavily constrained by anastomotic accessibility, particularly in altered post-hepatectomy anatomy. This review evaluates the clinical burden and anatomical barriers of conventional Roux-en-Y reconstruction and introduces “future-proof” biliary reconstruction strategies aimed at preserving lifelong therapeutic access. Methods: A comprehensive literature review was conducted to synthesize current evidence regarding the epidemiology, risk factors, and clinical consequences of benign HJS. We analyzed the technical limitations of contemporary interventions and critically reviewed the historical evolution of access-oriented surgical modifications, including access loops and modified enteric configurations. This narrative review was conducted through a structured search of PubMed, Scopus, and Web of Science for studies published between January 2000 and March 2026. Search terms included “hepaticojejunostomy”, “benign hepaticojejunostomy stricture”, “Roux-en-Y”, “balloon enteroscopy”, “EUS-guided biliary drainage”, “PTBD”, “access loop”, “jejunoduodenostomy”, and “biliary reconstruction”. Original articles, systematic reviews, meta-analyses, and relevant guideline papers published in English were included. Conference abstracts, editorials, and articles lacking sufficient clinical information were excluded. Results: Anatomical factors—such as excessive Roux limb length ($ > $50–70 cm), dense postoperative adhesions, sharp intestinal angulations, and complex multi-ductal hilar reconstructions—represent the primary drivers of endoscopic failure. Conventional reactive approaches address these barriers only after complications manifest, severely impacting patient quality of life and increasing healthcare utilization. Conversely, access-oriented strategies proactively incorporate long-term accessibility into initial operative planning. Specifically, Future Access Biliary Reconstruction (FABR)—utilizing a side-to-side jejunoduodenostomy between the elevated jejunal limb and the second portion of the duodenum—creates a direct, permanent route to the biliary limb, permitting rapid and reliable intervention via standard upper gastrointestinal endoscopy without compromising the primary hepaticojejunostomy. Conclusions: Future-proof biliary reconstruction represents a pivotal paradigm shift in hepatobiliary surgery, transitioning from purely functional restoration to proactive, lifelong disease management. Incorporating FABR during the index operation may eliminate anatomical barriers before they arise, potentially reducing reliance on invasive percutaneous interventions or high-risk surgical revisions. Prospective multicenter studies are warranted to validate its long-term safety, clinical efficacy, and optimal selection criteria.

Surgical Techniques Development doi: 10.3390/std15030031

Authors: Radu Alexandru Ilieș Vlad Alexandru Gâta Ștefan Țîțu Alex Victor Orădan Ioan Constantin Pop Simona Ioana Filip Gerald Gheorghe Filip Eugeniu Darii Iyad Shahin Răzvan-Valentin Scăunașu Maximilian Vlad Muntean

Background/Objectives: Robotic-assisted breast reconstruction with deep inferior epigastric perforator (DIEP) flap has been developed as a minimally invasive alternative to conventional open DIEP harvest, having the primary goal of reducing donor-site morbidity while preserving flap reliability. Methods: A targeted literature search was performed in PubMed using the keywords “robotic” AND “DIEP”. Following title, abstract and reference screening, 10 studies were included in the final analysis. The current narrative review summarizes the existing literature regarding robotic versus conventional DIEP flap reconstruction, concentrating on abdominal wall preservation, postoperative pain and recovery, operative time, flap survival, and complication rates, with respect to learning curve and feasibility. Results: The included studies demonstrate significantly shorter fascial incisions, together with reduced abdominal wall disruption in robotic DIEP harvest compared with conventional techniques. However, current evidence has not demonstrated that this anatomical difference translates into clinically significant reductions in donor-site morbidity. Some comparative studies also report lower postoperative pain scores and shorter hospital stay in robotic cohorts. Flap survival and overall complication rates appear comparable between robotic and conventional DIEP reconstruction. However, robotic surgery remains linked to longer operative times and higher infrastructural requirements. Conclusions: Robotic DIEP reconstruction represents a feasible and potentially advantageous evolution in autologous breast reconstruction, but larger prospective multicenter studies with long-term follow-up are necessary to establish definitive superiority over conventional techniques.

Surgical Techniques Development doi: 10.3390/std15030030

Authors: Alberto Busetto Alessandro Bonis Vincenzo Verzeletti Carla Andaloro Giovanni Comacchio Elisa de Franceschi Francesco Londero William Grossi Andrea Zuin Andrea Dell’Amore

Background/Objectives: Primary hyperparathyroidism (PHPT) is most commonly caused by a single cervical parathyroid adenoma; however, a minority of cases originate from ectopic glands, including intrathoracic localizations. Intrathoracic ectopic parathyroid glands (EPGs) are rare and pose significant diagnostic and therapeutic challenges due to their anatomical variability and overlap with other mediastinal pathologies. Methods: We retrospectively analyzed 13 consecutive patients with PHPT caused by intrathoracic EPGs, who underwent minimally invasive surgical resection between 2015 and 2024 at two Italian tertiary referral centers. Demographic characteristics, biochemical profiles, imaging findings, surgical approaches, intraoperative parathyroid hormone (ioPTH) kinetics, and postoperative outcomes were evaluated. Results: All patients underwent successful resection using video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS). Ectopic glands were identified in thymic, mediastinal, retroesophageal, paratracheal, and aortopulmonary locations. Postoperative normalization of calcium, phosphate, and PTH levels confirmed biochemical cure in all patients. No intraoperative complications or 30-day mortality were observed. Higher preoperative PTH levels were associated with longer operative times only in an exploratory, non-significant manner. Conclusions: Intrathoracic EPGs should be suspected in patients with PHPT and negative cervical imaging. Minimally invasive thoracic surgery provides safe and effective treatment with excellent biochemical outcomes. Elevated preoperative PTH levels may reflect increased surgical complexity, a hypothesis that warrants validation in larger cohorts.

Surgical Techniques Development doi: 10.3390/std15030029

Authors: Ei Ei Naing Khin Thandar Myint Roberto Roddi

The journal retracts the Case Report titled “Lacrimal Gland Prolapse: Case Report” [...]

Surgical Techniques Development doi: 10.3390/std15030028

Authors: Naoki Mimura Nobuo Takata Takehiro Okabayashi

Objectives: The incidence of distal gastric cancer has declined worldwide owing to successful Helicobacter pylori eradication and improvements in environmental and dietary factors. In contrast, adenocarcinoma of the esophagogastric junction (AEG) and proximal gastric cancer have become increasingly prevalent, creating a growing need for function-preserving surgical approaches. Proximal gastrectomy has emerged as an attractive alternative to total gastrectomy because of its potential advantages in nutritional preservation and postoperative quality of life. However, concerns regarding postoperative reflux esophagitis have historically limited its widespread adoption. This review aimed to summarize the evolution of reconstruction after proximal gastrectomy and evaluate the advantages, limitations, and clinical outcomes of contemporary reconstruction techniques. Methods: A narrative review of the current literature was performed, focusing on reconstruction strategies following proximal gastrectomy. Major contemporary techniques, including double-tract reconstruction (DTR), double-flap reconstruction (DFT; Kamikawa method), side-overlap fundoplication by Yamashita (SOFY), and Toupet-like fundoplication reconstruction, were reviewed. Comparative evidence regarding reflux control, nutritional outcomes, operative complexity, anastomotic complications, and postoperative quality of life was examined. Results: Substantial advances in reconstructive techniques have significantly improved functional outcomes after proximal gastrectomy. DTR provides reliable reflux prevention, reproducibility, and broad applicability in minimally invasive surgery. DFT achieves excellent anti-reflux efficacy while preserving physiological food passage through the remnant stomach. SOFY offers favorable functional outcomes with reduced technical complexity and is particularly suited to laparoscopic and robotic surgery. Toupet-like reconstruction represents a promising alternative with encouraging early clinical results. Comparative studies indicate that all contemporary anti-reflux reconstruction methods substantially reduce reflux esophagitis compared with conventional esophagogastrostomy. Although each technique demonstrates specific advantages and limitations, no single reconstruction method has consistently shown superiority across all clinically relevant outcomes, including reflux prevention, nutritional preservation, operative complexity, and quality of life. Conclusions: Modern reconstruction techniques have expanded the role of proximal gastrectomy as a function-preserving alternative to total gastrectomy for proximal gastric cancer and AEG. Current evidence suggests that DTR, DFT, SOFY, and Toupet-like reconstruction can all achieve satisfactory oncological and functional outcomes when appropriately applied. Rather than identifying a universally superior procedure, contemporary practice should emphasize individualized reconstruction based on patient characteristics, surgeon expertise, and institutional experience. Future advances in robotic surgery, perioperative care, and standardized outcome assessment are expected to further optimize long-term outcomes following proximal gastrectomy.

Surgical Techniques Development doi: 10.3390/std15030027

Authors: Egidio Riggio

The annual congress of the Italian Association of Plastic Aesthetic Surgery (AICPE), with more than 700 members, represents one of the most relevant conference meetings in Europe relating to Aesthetic Plastic Surgery due to the number of participants and due to the faculty of invited speakers chosen for their renowned scientific value. The 13th meeting was held in Rome (Italy) from 10 to 12 April 2026. Key focus areas of the scientific program concerned breast (reduction, lifting supported or not by mesh, implant surfaces, augmentation), face and neck (lifting, blepharoplasty, malar implants, feminization), body (abdominoplasty and torsoplasty, post-partum and ex-obesity surgery, body and limb contouring, complication treatments) and nose surgery combined with medical innovations in energy devices, threads and aesthetic medicine procedures. Special attention was also given to the theme of the therapeutic role of aesthetic surgery, which is increasingly becoming an integral part of a clinical pathway useful for restoring the patient’s psycho-physical balance. Presented here is a report of the abstracts accepted due to their innovative or cutting-edge content that were selected to be given as oral presentations during the congress sessions. The 2nd edition of the Saccomanno memorial award for the best abstract presented by a young surgeon has been organized with the endorsement of Surgical Techniques Development by MDPI.

Surgical Techniques Development doi: 10.3390/std15020026

Authors: Mohannad Almomani Aimilia Bilali Nikolaos Drimalas Ioannis M. Vlastos

Background/Objectives: Septal deviation is a common cause of nasal obstruction, and achieving long-lasting septal straightening while preserving cartilage remains a surgical challenge. In this study, we describe and evaluate a simple suture technique designed to effectively straighten the nasal septum in both experimental and clinical settings. Methods: The technique combines cartilage scoring with the placement of a mattress suture to correct septal deformities. It was first tested in vitro using fifteen rabbit ear cartilage specimens and subsequently applied in vivo in a clinical series of forty-five patients presenting with septal deviation. The approach was assessed for ease of application, suitability in difficult anatomical regions (including severe caudal or dorsal deviations), cartilage preservation, and durability of correction. Clinical outcomes were followed for up to twelve months. Results: The combined scoring and mattress suture technique successfully straightened cartilage in both experimental and clinical applications. The method proved technically straightforward and applicable even in challenging septal areas. It allowed for conservative management with increased cartilage preservation. In the patient cohort, initial favorable outcomes were maintained throughout follow-up period. Conclusions: This simple suture technique represents an effective and conservative method for septal straightening. It is easy to perform, preserves cartilage, and seems to provide stable short- to mid-term results. The method may be particularly useful in cases of severe caudal or dorsal septal deviation.

Surgical Techniques Development doi: 10.3390/std15020025

Authors: Stephan Raab Evaldas Girdauskas Sebastian Reindl

Objective: Osteosynthesis in the case of a sternal wound infection is challenging. It requires osteosynthesis systems that go beyond the usual wire techniques. In principle, there are three different systems, namely plates with locking screws, clips, and distance systems, which are the original methods used in chest wall reconstruction. The aim of this study is to assign these systems to the corresponding sternal pathologies. Patients and methods: This is a retrospective single-center analysis. Bone pathology is divided into three grades: grade I (good substance/no fractures), grade II (good substance/few transverse fractures), grade III (poor substance/substance defects/multiple transverse fractures). The individual osteosynthesis systems are assigned to the different grades accordingly. The suitability of the individual systems is analyzed in the short term and long term. Results: A total of 130 patients were included. Stable osteosynthesis was achieved in all patients. For grade I defects, 75 plates and 24 clips were used. For grade II defects, mainly plates (255) but also clips (16) were used. A distance system was used 24 times for grade III defects. One plate fractured. No other implant-related complications occurred. Discussion: If the different osteosynthesis systems are used according to the bone pathology, a stable chest wall can be restored in all patients. The individual systems have their own specific characteristics, which must be taken into account with regard to the suitability and invasiveness of the procedure. No single system is suitable for treating all sternal pathologies.

Surgical Techniques Development doi: 10.3390/std15020024

Authors: Francesca Grussu Eufemia Cetani Marta Cajozzo Gaetano Paolo Dicorato Jacopo Maria Frattaroli Mario Zama

Background/Objectives: Epidermolysis bullosa (EB) comprises a heterogeneous group of rare inherited skin-fragility disorders in which even minimal trauma can cause blistering, chronic wounds, scarring, and functional impairment. After surgical release of EB hand deformities, wound coverage is challenging because autologous split-thickness skin grafting creates an additional donor-site wound in already fragile tissue. This preliminary case series reports our single-center pediatric experience using intact fish skin grafting (iFSG) as an adjunct after EB hand surgery. Methods: We conducted an observational case series of five pediatric patients with dystrophic EB, including eight operated hands, treated between December 2022 and December 2025. iFSG was applied after the release of contractures and/or pseudosyndactyly. Primary outcomes were time to complete re-epithelialization, need for re-application, need for autologous grafting, and early complications. Secondary outcomes included dressing-related pain assessed with an age-appropriate visual analog scale during awake dressing care, dressing burden, and early recurrence signals. Results: The iFSG application was feasible in all cases. One localized second application was required, and no patient required autologous split-thickness skin grafting. Mean dressing-related pain was 1.6 on the visual analog scale, and mean time to complete re-epithelialization was 47.6 days. No allergic reactions occurred. Healing was slower in the two most severe bilateral mitten-hand cases, and one patient developed limited dorsal disepithelialization attributed to prolonged dressing contact on extremely fragile skin. One partial recurrence of pseudosyndactyly was observed during follow-up without the need for revision surgery. Conclusions: iFSG was feasible in this small preliminary pediatric dystrophic EB hand surgery series and may provide a biologically active scaffold that supports secondary closure while avoiding autologous donor-site creation. Because of the rarity of the disease, the limited sample size, the absence of a comparator group, and the limited follow-up, these findings should be interpreted cautiously. Larger multicenter studies with standardized functional, pain, recurrence, and caregiver-reported outcomes are needed to define the role of iFSG in EB hand reconstruction. ABILHAND-Kids was also administered to patients/caregivers and suggested encouraging perceived improvement in postoperative hand use and independence in daily activities.

Surgical Techniques Development doi: 10.3390/std15020023

Authors: Egidio Riggio

The annual congress of the Italian Association of Plastic Aesthetic Surgery (AICPE) is one of the most relevant conference meetings in Europe concerning aesthetic plastic surgery as there are a number of participants, over 400, and an international team of invited speakers chosen for their renowned scientific value. The 12th meeting was held in Rimini (Italy) from 6 to 8 June 2025. The scientific issues concerned new advancements in aesthetic surgery. This book of abstracts contains research related to facial surgery, body contouring, breast surgery, and rhinoplasty, also including aesthetic medicine, AI’s impact on the medical profession, and forensic medicine. For the first time, the AICPE established an award in memory of Flavio Saccomanno for the best paper presented by a young surgeon with the endorsement of Surgical Techniques Development by MDPI.

Surgical Techniques Development doi: 10.3390/std15020022

Authors: Harbi Khalayleh George Asfour Adnan Shawahna Rafael Miller Barak Bar-Zakai

Background: Laparoscopic partial splenectomy (LPS) is a technically demanding procedure. The main difficulty when considering LPS is the bleeding risk. With advancements in technology and a deeper understanding of spleen vascular distribution, LPS has emerged as a feasible and safe procedure. Methods: There are many techniques used in order to prevent bleeding; in our case, we performed LPS using transient main splenic artery clamping. Our case represents a 65-year-old man who was diagnosed with a space-occupying lesion in the lower pole of the spleen and underwent LPS by temporary non-selective occlusion of the splenic artery. Results: The LPS was successfully performed. The surgery length was about 105 min, and it took about 48 min from placement of the bulldog on the splenic artery (warm ischemia), transecting the splenic parenchyma and release of the bulldog. The estimated blood loss was less than 50 mL. The recovery was smooth and uneventful, and the patient was discharged on the third postoperative day. Conclusions: LPS with temporary occlusion of the main trunk of splenic artery is shown to be an effective, practicable and reliable method that is associated with minor operative blood loss.

Surgical Techniques Development doi: 10.3390/std15020021

Authors: Gabriel Stan Horia Orban Rares Deculescu Nicolae Gheorghiu

Background: Total knee arthroplasty in patients with hemophilia remains the most effective surgical intervention for end-stage hemophilic arthropathy, yet it poses unique surgical and perioperative challenges that are rarely encountered in standard osteoarthritis cases. This article synthesizes technical, anatomical, and perioperative considerations specific to hemophilic patients and integrates prospective clinical data derived exclusively from the hemophilic cohort of our long-term study (twenty patients, twenty knees; 2015–2024). Emphasis is placed on deformity correction, bone loss management, implant selection, hemostatic strategies, transfusion patterns, and perioperative pitfalls. The objective is to provide a comprehensive narrative reference for surgeons managing complex hemophilic knees, consolidating both evidence-based recommendations and practical perioperative “tips and tricks” accumulated across more than a decade of clinical experience. Methods: This prospective observational study evaluated twenty consecutive male patients with hemophilia who underwent primary total knee arthroplasty for advanced hemophilic arthropathy between 2015 and 2024 at our institution. The following variables were collected: operative time measured from skin incision to skin closure, postoperative transfusion requirement, length of hospitalization measured in days, early postoperative complications, and functional recovery as assessed by the Knee Society Score. Early complications included postoperative bleeding or hematoma, superficial or deep infection, and stiffness requiring intensive physiotherapy or manipulation under anesthesia. Results: The mean age at the time of surgery was 44.8 years with a standard deviation of 7.2 years, ranging from 31 to 59 years. The mean operative time in the hemophilic cohort was 154.54 min with a standard deviation of 18.36 min. The range of operative time was from 120 to 180 min. Nine of the twenty patients, representing 45 percent, required postoperative blood transfusion. The mean length of hospital stay in the hemophilic cohort was 12.3 days with a standard deviation of 2.38 days, ranging from 9 to 17 days. The mean Knee Society Score improved from 38 points preoperatively to 82 points at final follow-up, representing a mean increase of 44 points. Conclusions: Total knee arthroplasty in hemophilic patients is safe and effective when specialized surgical techniques, comprehensive synovectomy, precise deformity correction, optimized hemostasis, and structured postoperative coagulation factor replacement are implemented. Functional outcomes and prosthetic survival are excellent in experienced centers.

Surgical Techniques Development doi: 10.3390/std15020020

Authors: Doinel G. Rădeanu Valeriu Bronescu Octavian D. Palade Alma Aurelia Maniu Constantin Stan

Background/Objectives: Tonsillectomy remains one of the most frequently performed procedures in pediatric otolaryngology. This study compared the clinical efficacy and postoperative morbidity of coblation tonsillectomy (Group A) versus traditional cold dissection (Group B), focusing on postoperative pain, recovery time, and hemorrhagic complications. Methods: A prospective, randomized, single-blinded study was conducted involving 100 pediatric patients (n = 50 per group) aged 3 to 17 years. Patients were monitored for 10 days postoperatively. The primary outcome was pain intensity, measured twice daily using the Wong–Baker FACES Pain Rating Scale. Secondary outcomes included operative time, analgesic consumption, time to return to a normal diet, and secondary hemorrhage rates. Results: The mean operative time for Group A was significantly shorter (18.5 ± 4.2 min) compared to Group B (24.1 ± 5.6 min; p < 0.05). Pain assessment showed significantly lower mean pain scores for the Coblation group during the critical first week. For instance, on Post-op Day 1, the mean pain score was 3.2 for Group A vs. 5.8 for Group B (p < 0.001). Patients in Group A returned to a normal solid diet significantly earlier (mean day 5.2 ± 1.1) than those in Group B (mean day 7.4 ± 1.5; p < 0.01). Secondary hemorrhage occurred in 1 case (2%) in Group A and 1 case (2%) in Group B (p = 1.00). Conclusions: Coblation tonsillectomy significantly reduces postoperative pain and accelerates recovery without compromising the safety profile. The clinical benefits, despite the higher procedural cost, justify its preference in modern pediatric surgical practice due to improved quality of life for the patient.

Surgical Techniques Development doi: 10.3390/std15020019

Authors: Alvaro Perazzo Pedro Rafael Vieira de Oliveira Salerno Mariana Ferreira Paulino Vitoria de Ataide Caliari Isabella Martins Ribeiro Roberto Lorusso Ricardo de Carvalho Lima Pedro Rafael Salerno

In the original publication [...]

Surgical Techniques Development doi: 10.3390/std15020018

Authors: Alice Montagna Giuseppe Niccoli Fabio Nesta Marco Pasqualon Francesco Benazzo Rudy Sangaletti

Introduction: Plantar fasciitis is a common cause of heel pain in adults, with a significant impact on quality of life and athletic performance. While conservative treatments are effective in most cases, a subset of patients remains symptomatic and may require surgical intervention. Minimally invasive techniques, such as bipolar radiofrequency (RF) coblation using the TOPAZ system, have emerged as promising alternatives to traditional open or endoscopic procedures. Methods: This retrospective study evaluated the clinical outcomes of 49 consecutive patients (20 males and 29 females; mean age 54.3 ± 11.4 years; mean BMI 25.3 ± 3.2, range 21.5–34.7) with chronic plantar fasciitis unresponsive to at least six months of conservative treatment. The affected side was left in 24 patients and right in 25, and 35 patients were regularly engaged in sports prior to symptom onset. All patients underwent percutaneous bipolar RF coblation using the TOPAZ device between July 2019 and November 2024. Patient-reported outcome measures—including the Visual Analog Scale (VAS), AOFAS Ankle–Hindfoot Score, SF-36, and Tegner Activity Scale—were collected at the final follow-up (mean 41.7 ± 18.3 months, range 6–71). Results: Statistically significant improvements were observed in pain and function: mean VAS decreased from 8.5 to 3.1 (p < 0.001), and American Orthopaedic Foot and Ankle Society (AOFAS) pain and function scores improved from 2.5 and 12.75 to 28.75 and 38.75, respectively (p < 0.001). The mean Tegner score increased from 1.3 to 4.1 (p < 0.001), with 100% of previously active patients returning to sport. No major complications or reoperations were reported. Conclusions: Percutaneous bipolar RF coblation appears to be a safe and effective treatment for recalcitrant plantar fasciitis, offering significant pain relief, functional improvement, and a high return-to-sport rate with minimal morbidity. This technique may represent a valuable intermediate option between conservative care and open surgery.

Surgical Techniques Development doi: 10.3390/std15020017

Authors: Doinel G. Rădeanu Constantin Stan Valeriu Bronescu Octavian D. Palade Alma A. Maniu

Background/Objectives: Chronic otitis media with effusion (OME) is the primary cause of conductive hearing loss in children. High recurrence rates following conventional surgery are often linked to incomplete nasopharyngeal clearance or persistent adenotonsillar biofilms. This study evaluates the long-term impact of endoscopic coblation adenotonsillotomy on middle ear clearance and disease recurrence compared to conventional curettage adenoidectomy. Methods: We conducted a prospective comparative study on 142 pediatric patients with persistent OME. Participants were allocated into Group A (Endoscopic Coblation Adenotonsillotomy, n = 72) and Group B (Conventional Curettage Adenoidectomy, n = 70). Groups were homogeneous regarding age, gender, and baseline audiological parameters (p > 0.05), all presenting with moderate conductive hearing loss and Type B/C tympanograms. Primary outcomes included tympanometric normalization (Type A conversion), auditory gain (Air–Bone Gap closure), and the rate of secondary ventilation tube (VT) insertion, monitored at 1, 3, 6, and 12 months. Results: At the 1-month follow-up, Group A showed a higher normalization rate than Group B (75.0% vs. 60.0%), though this was near the threshold of statistical significance (p = 0.058). However, at 3, 6, and 12 months, the coblation group demonstrated significantly higher recovery rates (p < 0.05). By 12 months, 94.4% of Group A maintained a Type A tympanogram compared to 78.5% in Group B. Group A achieved a significantly lower mean ABG at 12 months (8.2 ± 3.1 dB vs. 12.6 ± 5.4 dB, p < 0.001), reflecting a superior auditory gain (20.2 dB vs. 15.3 dB). Furthermore, the recurrence rate was significantly lower in Group A (4.1% vs. 15.7%, p = 0.021), resulting in a substantially lower requirement for secondary VT insertion compared to the conventional group (2.7% vs. 12.8%, p = 0.018). Conclusions: Endoscopic coblation adenotonsillotomy provides significant long-term clinical advantages over conventional curettage. By ensuring precise, atraumatic clearance of the Fossa of Rosenmüller and addressing the tonsillar biofilm reservoir, this technique achieves more stable middle ear aeration and superior auditory recovery, significantly reducing the necessity for secondary surgical interventions at one year.

Surgical Techniques Development doi: 10.3390/std15020016

Authors: Francesco Grasso Fabio Baldanza Chiara Cambiaso Marco Pensabene Maria Sergio Maria Rita Di Pace

Background/Objectives: This study aims to develop and validate a reproducible training model, built using common hospital items, for laparoscopic inguinal hernia repair with an intracorporeal suturing approach, specifically focusing on iliopubic tract redress in pediatric patients. Methods: Pediatric surgery residents and consultants were instructed on model building and engaged in training sessions. They practiced for four weeks with the handcrafted model and completed a post-simulation survey. The time taken to conclude the training task and the modified Objective Structured Assessment of Technical Skills score were compared between the initial and last sessions at the end of the training period. Additionally, the time required by consultants to perform the laparoscopic procedure in vivo, intraoperative complications, and recurrence rates were analyzed from the time they started the training. Results: A feasible model was created using a colostomy dressing support, Penrose drains, Foley catheters, feeding tubes, and surgical gloves to simulate. The sample involved a total of twelve residents and five consultants with an average age of 33 years old. All participants successfully completed the task during the session. Since the consultants started their training on the model, the operative results for laparoscopic inguinal hernia repair in the theater have improved. Conclusions: Training experience on this model led to improve laparoscopic skills such as cutting and dissection and intracorporeal tying and knotting. This study confirms that training outside clinical practice can significantly benefit laparoscopic proficiency and safety in vivo.

Surgical Techniques Development doi: 10.3390/std15020015

Authors: Mohammad Al-Dweeri Alvin C. Jones

Background/Objectives: Superior cluneal nerve entrapment syndrome (SCNES) is an underrecognized cause of chronic low back pain, particularly in adolescents where published experience is limited. This article describes a reproducible open surgical technique for superior cluneal nerve (SCN) decompression. Methods: We outline indications and relative contraindications, required instrumentation, key surface landmarks, and a stepwise operative approach. The nerve is identified where SCN branches traverse the thoracolumbar fascia and fibro-osseous tunnel near the posterior iliac crest. Decompression is performed via limited fasciotomy and release of surrounding soft tissues, with attention given to identifying additional branches requiring release. Results: The technique provides consistent exposure and decompression of the SCN branches using an approximately 5 cm oblique incision centered over the expected crossing point (about 7 cm lateral to the midline and roughly 4 cm lateral to the PSIS). Pearls and pitfalls are provided to reduce peri-incisional numbness and avoid thermal injury to the nerve. Conclusions: Open SCN decompression is a focused procedure that can be considered after confirmation of SCNES by clinical criteria and response to diagnostic block. Standardizing technique and postoperative care may facilitate broader adoption and future outcome studies in pediatric populations.

Surgical Techniques Development doi: 10.3390/std15020014

Authors: Shuvalaxmi D. Haselton Jason Michael Cholewa Udoka Okaro Roger H. Emerson

Background: Cemented fixation remains the standard for total knee arthroplasty (TKA), with Palacos® R considered the gold standard bone cement. However, more cost-efficient alternatives, like Biomet Bone Cement® (BBC), require evaluation to confirm comparable outcomes. This retrospective 5-year study compares the clinical safety, performance, and radiographic outcomes of BBC versus Palacos-R in primary TKA, highlighting BBC’s potential as a comparable, cost-effective option amid the increasing cost of outpatient surgeries. Methods: This is a single-center, retrospective study of 128 consecutive patients undergoing primary TKA, evaluated over 5 years. The first 64 patients received Palacos-R, and the subsequent 64 patients received BBC. Radiographic outcomes, including cement gaps, radiolucency, periprosthetic osteolysis, and subsidence, were assessed using the Knee Society Radiographic scheme at immediate post-operative, 6-month, 1-year, 3-year, and 5-year intervals. Clinical outcomes were measured using the Knee Society Score (KSS) and the University of California Los Angeles Activity (UCLA) score. Statistical analyses included chi-square, Fisher’s exact tests, and t-tests (p < 0.05). Results: Cement gaps were significantly higher in the Palacos-R cohort at immediate postop (p = 0.0002) and 1-year (p = 0.0003), with no significant difference at 3 and 5 years. Radiolucency was non-progressive (<2 mm) in both cohorts. KSS was significantly higher in the Palacos-R group at 6 months, 1 year, and 3 years (p < 0.001), but equivalent at 5 years (p = 0.42). UCLA scores showed no differences. No revisions were required in either cohort. Conclusions: While BBC demonstrated comparable radiographic stability and clinical outcomes to Palacos at 5 years with no revisions in either cohort, the absence of preoperative KSS and UCLA scores is a major limitation that prevents adjustment for baseline function and limits interpretation of the early postoperative KSS differences.

Surgical Techniques Development doi: 10.3390/std15010013

Authors: Elisabetta Giani Ilaria Morelli Susanna Gadda Sanzo Andrea F. Fusaro Alessandro Ivone Giacomo Galanzino Roberto E. Vanelli

Background: Unicompartmental knee arthroplasty (UKA) is an effective treatment for isolated compartment knee osteoarthritis, but it is associated with a higher risk of revisions. UKA-to-TKA conversions remain surgically challenging. In particular, the restoration of correct femoral rotation is difficult, mainly because of bone loss and altered anatomical landmarks. We describe a novel imageless robotic-assisted technique for UKA-to-TKA conversion using the ROSA™ robotic system and report a representative clinical case. Methods: After a standard medial parapatellar approach and joint exposure, the landmarks are registered with the UKA in situ, followed by the standard workflow for a robotic-assisted primary TKA according to the “inverse functional alignment” philosophy (virtual planning, tibial cut, planning adjustment, distal femoral cut and planning adjustment). At last, the femoral component rotation is defined using the FuZion® tensioner, with the UKA femoral component being left in situ to compensate for the lateral posterior condyle bone loss. Results: A 72-year-old female patient underwent robotic-assisted lateral UKA-to-TKA conversion due to aseptic loosening of the tibial component. Accurate bone resection, restoration of alignment, and soft tissue balancing were achieved, avoiding the use of augments. Postoperative recovery was uneventful, with satisfactory clinical and functional outcomes at 3-month follow-up. Conclusions: Imageless robotic-assisted UKA-to-TKA conversion using the ROSA™ system seems a valuable aid in these complex scenarios. To our knowledge, this is the second report describing this procedure using the ROSA™ robot and the first presenting a distinct surgical technique. Further studies on larger cohorts are needed to confirm this technique efficacy and possible limitations.

Surgical Techniques Development doi: 10.3390/std15010012

Authors: Fahim Kanani Leonardo Chamovitz Rijini Nugzar Mohammad Mohtaseb Anas Salhab Mordechai Shimonov Firas Abu Akar

Objectives: To evaluate the short-term safety (30-day and in-hospital morbidity and mortality) and technical feasibility of uniportal video-assisted thoracic surgery (U-VATS) for anatomical lung resection in octogenarians (≥80 years) compared with younger patients (<80 years) at a single center. Methods: Ninety consecutive patients undergoing U-VATS anatomical lung resections between January 2020 and January 2024 were retrospectively analyzed. Patients were stratified by age: 60 patients < 80 years and 30 octogenarians ≥ 80 years. Propensity score matching (nearest-neighbor, 1:2 ratio, caliper 0.2 SD) yielded a matched cohort of 60 patients (40 younger, 20 octogenarians) for comparative analysis. Results: After matching, standardized mean differences (SMD) were <0.25 for most covariates, indicating good balance. Octogenarians demonstrated lower FEV1 (75.2 ± 15.3% vs. 87.5 ± 18.2%, p = 0.012) and DLCO (68.4 ± 12.1% vs. 78.5 ± 14.3%, p = 0.009), consistent with age-related pulmonary changes. Charlson Comorbidity Index was higher (5.3 ± 1.2 vs. 3.8 ± 1.4, p = 0.001). Surgical parameters were comparable: operative time (143.80 ± 42.3 vs. 136.55 ± 38.7 min, p = 0.524), blood loss (median 80 [IQR 50–120] vs. 95 [IQR 60–130] mL, p = 0.742). Zero conversions occurred. Major complications (Clavien–Dindo ≥ 3) occurred in 10% vs. 0% (absolute risk difference 10%, 95% CI: −3.2% to 23.2%). No 30-day mortality. 90-day mortality: 5% vs. 0% (p = 0.333); one-year: 15% vs. 0% (p = 0.035). Conclusions: U-VATS is technically feasible in carefully selected octogenarians with comparable intraoperative parameters to younger patients. Postoperative recovery differed meaningfully, with higher delirium rates, longer hospitalization, and greater rehabilitation needs. One-year mortality was higher in octogenarians, reflecting competing comorbid risk rather than surgical harm. Residual imbalance in comorbidity burden and pulmonary reserve after matching limits causal inference. These hypothesis-generating findings support U-VATS in selected octogenarians when comprehensive geriatric assessment and structured delirium prevention guide perioperative management; validation in larger multicenter prospective studies is required.

Surgical Techniques Development doi: 10.3390/std15010011

Authors: Jason J. Haselhuhn David W. Polly Todd J. Pottinger Kari Odland Jonathan N. Sembrano Christopher T. Martin Kristen E. Jones Nathan R. Hendrickson

(1) Background and introduction: High-demand lumbosacral fusions are often supplemented with sacral-alar-iliac (SAI) screws. The idealized SAI trajectory was estimated to traverse 35 mm of sacrum before crossing the sacroiliac (SI) joint. However, there is debate on how much osseous purchase SAI screws achieve. The goal of this study was to determine the amount of osseous engagement achieved using a porous fusion–fixation screw (PFFS) when placed in a stacked SAI configuration. (2) Materials and methods: We retrospectively reviewed 40 consecutive patients who underwent sacropelvic fixation with stacked PFFS at our institution from 1 June 2022 to 30 June 2023, using intraoperative computed tomography (CT)-based computer navigation. A snapshot of each screw was taken and the length of purchase within the sacrum and ilium was measured on the axial image along the anterior and posterior aspect of each screw. Nineteen patients did not have adequate images available for review and were excluded. (3) Results: The overall mean anterior sacral engagement was 38.6 mm (±8.2 mm), which was found to be statistically significantly greater than the hypothesized threshold of 35 mm (p < 0.001), while posterior sacral engagement was 28.1 mm (±8.6 mm), which was not found to be statistically significantly greater than the hypothesized threshold of 35 mm (p = 1). The mean difference in sacral engagement between the anatomical location for the cephalad screws was 10.3 mm (p < 0.001) and 10.6 mm (p < 0.001) for the caudal screws. The total sacral surface area available for bone ingrowth for bilateral stacked PFFS was calculated to be 3338.3 mm2, while the total iliac surface area available for bone ingrowth was 4364.8 mm2. A mean difference in surface area availability between anatomical locations was −689.5 mm2 (p < 0.001) for the sacrum and 689.5 mm2 (p < 0.001) for the ilium. (4) Discussion and conclusions: The SAI trajectory screws in this cohort of patients achieved approximately 39 mm of sacrum engagement anteriorly and 28 mm posteriorly. This is consistent with prior estimates based on the idealized SAI pathway through the sacrum. PFFSs allow for simultaneous sacropelvic fixation and SI joint fusion, which may reduce the incidence of de novo SI joint pain in patients with long fusion constructs.

Surgical Techniques Development doi: 10.3390/std15010010

Authors: Muhammad Khatib Assil Mahamid Dror Robinson Hamza Murad Eitan Lavon Feras Qawasmi Ali Yassin Mustafa Yassin

Background: Limb-salvage surgery using extendable distal femoral endoprostheses has become the standard reconstruction following tumor resection in skeletally immature patients, allowing continued growth and improved function. However, mechanical complications, particularly tibial pain, remain challenging and poorly understood. This study aimed to identify radiographic predictors of tibial pain and evaluate their potential utility in early risk detection. Methods: A retrospective cohort study was conducted of 29 skeletally immature patients (mean age 10.4 years) who underwent expandable distal femoral endoprosthetic replacement between 2008 and 2018 at a tertiary orthopedic oncology center. Standardized radiographs were analyzed at 6 months and final follow-up (mean 75 months) to assess cortical thickness, stem-to-cortex distances, stem migration, stress shielding, pedestal formation, and periosteal reaction. Associations between radiographic parameters and tibial pain were assessed using multivariable logistic regression, t-tests, and chi-square analyses. Results: Seventeen patients (58.6%) developed activity-limiting tibial pain requiring analgesics, as documented during follow-up. Mean medial and lateral cortical thickness increased from 3.0 mm and 3.4 mm to 4.1 mm and 5.1 mm, respectively. The logistic regression model demonstrated strong explanatory power (Pseudo R2 = 0.57, p = 0.004). Medial cortical thickness at last follow-up was the only significant independent predictor of tibial pain (p = 0.042), and was significantly associated with tibial pain. Patients with tibial pain exhibited greater medial cortical thickening (p < 0.001). Stem migration (φ = 0.421, p = 0.065), stress shielding (φ = 0.476, p = 0.044), pedestal formation (φ = 0.608, p = 0.004), and periosteal reaction (φ = 0.569, p = 0.008) were also associated with pain. Conclusions: Medial cortical hypertrophy emerged as a potential radiographic biomarker for tibial pain. after expandable distal femoral endoprosthesis in growing patients. The findings suggest that cortical remodeling, stress shielding, and pedestal formation collectively reflect stem micromotion and bone adaptation. Early radiographic surveillance of these parameters warrants further investigation in prospective studies to determine their clinical utility. Larger multicenter studies are warranted to validate these predictors and refine postoperative monitoring protocols.

Surgical Techniques Development doi: 10.3390/std15010009

Authors: Edgar G. Ordóñez-Rubiano Antonia Cadavid-Cobo Alejandra Ramírez-Romero Ana S. Rincón-Díaz Luisa F. Figueredo Martín Pinzón Oscar F. Zorro Javier G. Patiño-Gómez Diego F. Gómez-Amarillo Fernando Hakim

Background: In the last few decades, endoscopic endonasal approaches (EEA) have revolutionized surgical access to the sellar region and anterior cranial fossa (ACF). One technique, the endoscopic endonasal transethmoidal transcribriform approach (EETTA), offers distinct advantages over traditional open transcranial approaches, such as reduced morbidity, shorter hospital stays, faster recovery, and a reduced risk of neurological deficit due to less brain tissue manipulation. Methods: We present a comprehensive step-by-step description of the EETTA surgical technique, illustrated through four representative cases of varying pathologies treated at our institution. The anatomical boundaries—including the lamina papyracea, anterior and posterior ethmoidal arteries, and frontal sinus—and the surgical corridor are detailed alongside indications, technical nuances, limitations, and operative recommendations. Results: Four cases demonstrate the versatility of EETTA across diverse pathologies: two olfactory groove meningiomas (including one WHO grade 2 and one recurrent case with invasive skull base involvement), an esthesioneuroblastoma (ENB), and a recurrent inverted papilloma requiring combined transcranial and endoscopic resection. Near-total or gross-total resection was achieved in all cases. The indications, nuances, and limitations of this approach are discussed, along with tips for successful surgery. Conclusions: The EETTA represents an important minimally invasive option for ACF tumors extending into the nasal cavity, with midline involvement limited medially by the lamina papyracea. Success requires a thorough understanding of skull base anatomy, meticulous multilayer reconstruction techniques, and appropriate patient selection, based on the tumor location and lateral extension. While cerebrospinal fluid (CSF) leak remains the primary concern, contemporary techniques have substantially reduced this complication rate.

Surgical Techniques Development doi: 10.3390/std15010008

Authors: Francesco Maruccia Leonardo Savastano Marco Sandri Michele Bisceglia Franco Lucio Gorgoglione Elisabetta Mormone

Background: The extent to which bone marrow aspiration technique affects the biological quality of bone marrow aspirate and its clinical relevance in knee osteoarthritis remains uncertain. This study compares the efficacy of the traditional aspiration method and the Snap Back technique at two anatomical harvest sites, the posterior iliac crest and the proximal tibia. Methods: This ancillary post hoc analysis was conducted within a randomized trial comparing posterior iliac crest and proximal tibia harvest sites in 60 patients with unicompartmental knee OA. Aspiration technique (traditional vs. Snap Back) was selected intraoperatively and not randomized. BMA samples were analyzed for MSCs, mononuclear cells (MNCs), platelet concentration, and marrow purity. Clinical outcomes were assessed at baseline and six months using the Visual Analog Scale and the Western Ontario and McMaster Universities Osteoarthritis Index. Results: The posterior iliac crest yielded significantly higher MSC and MNC concentrations compared to the tibia, with superior purity and PLT counts observed using the Snap Back technique. Within each anatomical site, Snap Back aspiration provided improved cellular recovery over the traditional method. However, differences in clinical outcomes between groups were modest and did not consistently reach statistical significance. Conclusions: Both harvest site and aspiration technique were associated with substantial differences in the cellular composition of BMA. The withdrawal from posterior iliac crest combined with the Snap Back technique optimizes MSC yield and marrow purity, though clinical improvements appear independent of cellular concentration in the short term. These findings suggest that standardized aspiration protocols may be relevant for the biological efficacy of orthobiologic therapies in knee OA.

Surgical Techniques Development doi: 10.3390/std15010007

Authors: Corinne Vennitti Alyssa Althoff Timothy Hoggard Seth Yarboro Micheal Hadeed

Background/Objectives: Deltoid ligament injury has been reported in up to 40% of ankle fractures, as confirmed by arthroscopy. Despite the frequency of this injury, there are multiple methods of fixation, including use of sutures, anchors and grafts, with no consensus in the field on a gold standard of operative technique for deltoid ligament injuries identified in bimalleolar equivalent ankle fractures. This manuscript aims to describe a novel surgical technique for deltoid ligament repair in the setting of bimalleolar equivalent ankle fractures. Surgical Technique: In this technique, following fixation of the fibula in bimalleolar equivalent ankle fractures, barbed polydioxanone (PDS) suture is utilized for direct repair of the deltoid ligament. This technique can be completed with the patient either prone or supine, uses standard fluoroscopy for evaluation of the competency of the deltoid ligament, and utilizes a familiar anteromedial approach to the medial malleolus. When compared to using anchors for repair of the deltoid ligament, barbed PDS suture seems to provide an equivalent and cost-effective strategy for repair. Conclusions: Repair of the deltoid ligament using suture anchors is a widely accepted method that has been demonstrated to provide successful repair. However, these anchors can be costly and rely on appropriate fixation in the bone to provide long-term fixation. This suture technique seems to offer a reliable, cost-effective technique for deltoid ligament repair.

Surgical Techniques Development doi: 10.3390/std15010006

Authors: Fahim Kanani Adi Litmanovich Yonatan Lessing Nir Messer Boaz Sagie Guy Lahat Lior Orbach

Background/Objectives: Recurrence after curative gastrectomy for gastric cancer remains common, and treatment options are limited. In selected patients with isolated locoregional relapse, salvage re-gastrectomy may provide durable disease control. This study compared outcomes of salvage re-gastrectomy and chemotherapy for isolated locoregional recurrence. Methods: We reviewed 500 consecutive gastrectomies performed between 2010 and 2024. In total, 66 patients (12.8%) developed isolated locoregional recurrence after previous R0 resection: 25 underwent salvage re-gastrectomy, and 41 received chemotherapy. Propensity-score matching (intended 1:2) was used to balance clinical and pathologic variables, yielding 42 patients (17 surgery, 25 chemotherapy). The primary endpoint was overall survival (OS) from recurrence diagnosis; secondary endpoints included perioperative outcomes and patterns of treatment failure. Results: There were no 30-, 60-, or 90-day deaths after salvage re-gastrectomy. Overall mortality was lower in the surgical group (41.2%) compared with chemotherapy (80.0%; p = 0.010). Salvage re-gastrectomy was independently associated with better OS (HR 0.15, 95% CI 0.02–0.87, and p = 0.035). A longer disease-free interval correlated strongly with survival (ρ = 0.80 and p < 0.001). Surgical patients experienced fewer local (0% vs. 52%) and peritoneal (0% vs. 20%) recurrences. Conclusions: For carefully selected patients with late, isolated locoregional recurrence, salvage re-gastrectomy is feasible and associated with longer survival and improved local control compared with chemotherapy alone. Larger prospective studies are warranted.

Surgical Techniques Development doi: 10.3390/std15010005

Authors: Chia-Heng Chang Sheng-Po Hao Daniel Erick Amparado Chung-Yu Hao

Tracheostomal stenosis is a troublesome and distressing complication in laryngectomy. There are numerous techniques that describe dilatation of tracheostoma which are mostly performed under general anesthesia with the intermittent apnea technique. We report an alternative dilatation method using a Foley catheter for laryngectomee with stomal stenosis. One case was performed under high-frequency jet ventilation and the other case was carried out with a conventional anesthesia machine. The Foley catheter is used as a conduit for ventilation and the balloon on the Foley catheter was used as a dilatator.

Surgical Techniques Development doi: 10.3390/std15010004

Authors: Tomasz Klimczak Wojciech Ciesielski Wiktoria Aptacy Kinga Włudyka Agata Grochowska Adam Durczyński Janusz Strzelczyk Piotr Hogendorf

Background/Objectives: Endoscopic biliary stenting is the standard palliative intervention for malignant biliary obstruction, aimed at restoring ductal patency. Radiofrequency ablation (RFA) has been introduced as an adjunct technique to improve stent durability and patient outcomes. However, the literature remains inconclusive regarding which patients are most likely to benefit from the combination of RFA and stenting. Methods: We retrospectively described clinical outcomes of 24 patients undergoing endobiliary RFA combined with biliary stenting for malignant biliary obstruction. Post-procedural and 6-month outcomes were assessed using technical success and changes in serum bilirubin; procedure-related adverse events were extracted from available medical records. Results: Nineteen females and five males were included in the study. The most prevalent diagnoses were metastatic adenocarcinoma (n = 8) and cholangiocarcinoma (n = 6). 25% of patients did not complete the 6-month follow-up due to malignancy progression. 16 out of 18 maintained the patency of biliary stents. Repeat endoscopic intervention for suspected stent dysfunction was documented in one patient. When analyzed in an intention-to-treat manner (counting deaths before 6 months as failures), the corresponding 6-month patency/clinical success rate was 16/24 (66.7%). Conclusions: In this retrospective single-center experience, RFA combined with biliary stenting was feasible and was associated with maintained biliary drainage in a majority of patients who survived to the 6-month assessment.

Surgical Techniques Development doi: 10.3390/std15010003

Authors: Federica Ruggiero Pasqualino Sirignano Michele Rossi Edoardo Ronconi Francesco Stillo

Background: inferior mesenteric arteriovenous malformations and fistulas (IMAVMs/IMAVFs) are rare but clinically significant vascular anomalies characterized by abnormal communications between arterial and venous systems, leading to major hemodynamic disturbances. These lesions may be silent or cause disabling and difficult-to-diagnose symptoms such as colonic ischemia, portal hypertension, or even high-output cardiomyopathy. Methods: this narrative review aims to summarize current evidence on the pathophysiology, clinical features, diagnostic methods, and therapeutic management of these rare pathologies, supported by two our clinical cases. Conclusions: due to their rarity, multidisciplinary management and anatomical guided therapy are required for safe and lasting outcomes in patients with IMAVMs and IMAVFs.

Surgical Techniques Development doi: 10.3390/std15010002

Authors: Jai Scheerhoorn Max Herman Funnekotter Friso Schonck R. Arthur Bouwman Simon W. Nienhuijs

Background: Obesity and its accompanying complications have an influence on diurnal rhythm, potentially causing cardiometabolic disease. This study explores how weight loss due to bariatric surgery affects circadian rhythm disruptions measurable through wearable heart rate monitors. Methods: A single-center observational study was performed, in which patients who had undergone primary bariatric surgery 3 years ago with telemonitoring of vital parameters using a wireless accelerometer were eligible to participate. A Wilcoxon signed-rank test was conducted to evaluate the delta of, or amount of change in, circadian patterns between the baseline (before) and post-weight-loss peak, nadir, and peak–nadir heart rates. Results: In this cohort of 69 patients, 70% were female, with a median total weight loss of 31.4% towards a median BMI of 28.4 kg/m2. Analysis revealed significant changes in peak–nadir excursions post-weight loss. Peak, nadir, and peak–nadir differences showed a significant reduction in values in the post-weight-loss group. No significant correlations between other clinical endpoints and change in peak–nadir excursion were found in the multivariable regression models. Conclusions: In conclusion, this study reveals significant changes in circadian heart rate patterns before and after weight loss due to metabolic surgery. The results could add to the health benefits of bariatric surgery, as it could lower the incidence of diseases associated with changes in diurnal rhythm due to obesity. However, a clear clinical explanation is lacking, as no correlation with total weight loss nor other variables was substantiated.

Surgical Techniques Development doi: 10.3390/std15010001

Authors: David S. K. Mak Yu Tung Lo Mark B. W. Tan Dinesh S. Kumar Sharon Y. Y. Low

Background: Pediatric craniocervical junction (CCJ) anomalies consist of a unique subset of anatomically complex spine conditions. The aims of intervention are to achieve long-term stability, correct existing deformity, and prevent neurological compromise. However, surgery is challenging due to critical neurovascular and musculoskeletal structures in the limited operative space of a young child. Recently, the use of three-dimensional (3D) printed models has been demonstrated to be valuable neurosurgical adjuncts. We therein report the application of a 3D-printed model for a pediatric case with a complex CCJ condition. A systematic review of the related literature is concurrently performed. Case description: A 10-year-old male presented with torticollis associated with neck pain and progressive thoracic kyphosis. Neuroimaging reported an unfused os odontoideum inferior to the basion and anterior half of the C2 vertebral body and anteriorly angulated with the C1 anterior arch. Of note, there was a large vertebral vein coursing over the left C2 lamina that was predominantly draining into the CCJ venous plexus. A radiologically derived 3D model of the patient’s CCJ was printed and used for pre-operative planning, multi-disciplinary team discussion, and detailed counseling with the patient and caregivers. The patient underwent an uneventful C1–C2 posterior screw fixation and has recovered well since. Separately, we observed there is a paucity of publications specific to this topic. Conclusions: As demonstrated, a custom-made 3D model was useful for clinicians work through technical difficulties and improve the perioperative discussion process in an otherwise difficult case.

Surgical Techniques Development doi: 10.3390/std14040044

Authors: Radu Dan Necula Bogdan-Radu Necula Radu Vaidahazan Claudiu Gabriel Coraiu Adrian Burnariu Florin Lucian Sabou

Background: Covering the defects around the calcaneus is still a largely debatable subject. In the classical view, the defects at the level of the foot can be treated only by a free flap. In a modern approach, it has been observed that for small or moderate foot defects, a local flap can be used. Methodology: In this case series, we have retrospectively selected the patients who were admitted to the orthopedic department for a calcaneal fracture and who presented soft-tissue complications during the treatment. The patients have been selected from the past five years if they have undergone reconstructive surgery with a local or regional flap. Results: By applying the inclusion and exclusion criteria, we found that out of 79 patients who have been admitted to the orthopedic department, only two patients met the criteria. Two flaps have been used to treat the defects that developed at the level of the calcaneus after traumatic injury of the foot. The reverse-flow sural flap, as a tunneled flap, had a good evolution, without vascular suffering of the flap. On the other hand, for defects at the medial level of the calcaneus, we have used the dorsalis pedis flap. The healing was fast, and the patient presented no complications at the level of the donor site. Conclusions: Both flaps presented a good evolution. We try to emphasize through this article that soft tissue defects around the non-weight-bearing area of the heel can also be treated through a non-microsurgical option. These two options can help the ortho-plastic team to manage difficult cases by avoiding a free flap or a split-thickness skin graft.

Surgical Techniques Development doi: 10.3390/std14040043

Authors: Nadav Graif Ran Atzmon Aimee Steen Shai Factor Samuel Belmont Michal Dekel Ehud Rath Eyal Amar

Background: Septic arthritis of the hip (SAH) requires emergent surgical intervention. While open arthrotomy has been the traditional approach, arthroscopic treatment is emerging as an effective alternative. Tractionless techniques in adult populations remain understudied. Methods: Twenty-one patients (22 hips) met inclusion criteria. Six patients (7 hips) were excluded for age < 18 years, post-COVID osteomyelitis, prior hip surgery, or insufficient records, resulting in a final cohort of 15 patients. All fifteen patients underwent tractionless arthroscopic irrigation and debridement for suspected SAH (2014–2023). Inclusion required ≥2 clinical criteria (hip pain, limited range of motion, inability to bear weight, fever > 38 °C) AND ≥ 1 laboratory criterion (leukocytosis, elevated CRP, synovial WBC > 50,000, positive culture). Primary outcomes included Visual Analog Scale pain scores, inflammatory markers, and complications. Results: Median age was 33 years (range 20–76); 60% were female. VAS scores improved from 7 (6–10) to 1 (0–3) at discharge (p < 0.001). CRP levels decreased from 115 mg/L (35–206) to <5 mg/L (<5–9) postoperatively (p < 0.001). Positive cultures were obtained in 26.7% of cases, predominantly methicillin-sensitive Staphylococcus aureus. No perioperative complications occurred. Histopathological analysis revealed tenosynovial giant cell tumor (TGCT) in 33.3% of cases, representing an important differential diagnosis. Among non-TGCT cases, the culture-positive rate was 40%. No infection recurrence was observed during a minimum one-year follow-up. Conclusions: Tractionless arthroscopic irrigation and debridement appears effective for managing suspected SAH in adults, achieving significant improvements in pain scores and inflammatory markers without perioperative complications. This technique offers potential advantages by eliminating traction-related risks while maintaining effective joint debridement. Additionally, TGCT should be considered in the differential diagnosis of suspected SAH with culture-negative inflammatory arthropathy.

Surgical Techniques Development doi: 10.3390/std14040042

Authors: Sorin Lazarescu Mark-Edward Pogarasteanu Walid Bahaa-Eddin Bianca Mihaela Boga Marius Razvan Ristea Larisa Diana Ancuta Cristin Coman Dana Galieta Minca Robert Daniel Dobrotă Marius Moga

Background/Objectives: This article brings forward a novel methodology for the intra-op approach of forearm amputation stumps to facilitate their subsequent wireless connection to a neural prosthesis. A neural prosthesis offers the amputee more motor functions compared to myoelectric prostheses, but the neural prosthesis must be connected to the patient’s stump nerves. Methods: An experimental animal study was conducted on 15 Wistar rats. Under anesthesia, the sciatic nerve was carefully dissected and preserved using a folding technique to maintain maximum length without tension. Nerves were repositioned with consideration for future use with biocompatible conduits. Morphometric measurements (nerve length, external diameter, fascicle count) were performed, followed by statistical analysis of length–diameter correlations. Results: The techniques show that the length of the nerves in the amputation stump can be preserved and integrated into the muscle masses with appropriate methods and biomaterials, which ensures the transmission of motor impulses to control the movements of a prosthesis. Fibrosis and mechanical injury have a lower risk of occurring with the nerves protected in the muscle mass. Through statistical analysis we find that sciatic nerve length and diameter have a positive correlation (r = 0.71, p = 0.003), supporting anatomic plausibility for human extrapolation of results. Conclusions: The amputation technique preserves much of the nerve length and viability and is simple to perform. Neural electrode implantation can be facilitated by folding the nerve within a large muscle mass and using biomaterial conduits. Better rehabilitation of the patient may occur with the use of a prosthesis equipped with more functions and superior control.

Surgical Techniques Development doi: 10.3390/std14040041

Authors: Koichiro Yano Katsunori Ikari Masataka Kakihana Yuki Tochigi Ken Okazaki Lew C. Schon

Background: Achieving orthogonal coronal-plane alignment in total ankle arthroplasty (TAA) remains challenging in cases with severe varus deformity. We developed a novel tibial precutting technique for use in transfibular TAA to resolve intra-articular bony conflict and enable accurate implant placement without excessive medial soft tissue release. Methods: This technique involves a controlled resection of the lateral distal tibia to eliminate impingement between the tibial plafond and talar dome. From November 2019 to June 2022, 15 patients with coronal varus deformities >15° underwent transfibular TAA using this method. Twelve patients with ≥2 years of follow-up were retrospectively evaluated. Coronal alignment was assessed using the tibiotalar angle (TTA) on weight-bearing radiographs. Clinical outcomes were measured using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) and ankle range of motion (ROM) before surgery and at final follow-up. Results: The median TTA significantly improved from 20.4° (IQR: 18.1–24.3) preoperatively to 1.8° (IQR: 0.9–3.6) at the latest follow-up (p < 0.01), indicating successful correction to neutral alignment. All SAFE-Q subscales showed statistically significant improvement (p < 0.05), and ankle ROM also increased significantly postoperatively (p < 0.05). No cases of talar subsidence, implant lucency, fibular non-union, or avascular necrosis were observed. Conclusions: These results indicate that the TIBIA #2 technique can broaden the indications for transfibular total ankle arthroplasty in severe varus deformity while delivering meaningful clinical benefit. Nevertheless, confirmation in larger, controlled, and multi-centre cohorts is required before widespread adoption.

Surgical Techniques Development doi: 10.3390/std14040040

Authors: Francesco Laganà Bruno Carlo Brevi Alice Marzi Manfroni Francesco Arcuri Alessia Spinzia Emanuela Ardito Luigi Angelo Vaira Marjon Sako Edlira Baruti Papa Bernardo Bianchi

Introduction: Hemifacial hypoplasia is the second most common congenital craniofacial anomaly after cleft lip and palate. Mandibular ramus deficiency represents a key component of this condition, and vertical augmentation is traditionally managed with distraction osteogenesis. However, technical challenges related to device positioning and vector control continue to limit its reproducibility. This study aims to describe and compare three surgical techniques for mandibular ramus augmentation in hemifacial microsomia and to develop a surgical treatment algorithm based on individual anatomical characteristics and clinical complexity. Materials and Methods: From 2010 to 2022, eighteen patients with Pruzansky–Kaban grade I–IIb hypoplasia underwent staged orthodontic–surgical treatment at our institutions. The standard protocol included initial ramus vertical augmentation followed by bimaxillary osteotomy for asymmetry correction. The patients were equally divided into three groups of six patients each, based on the surgical technique employed. Three representative cases were selected to illustrate the evolution of our approach: (1) bidirectional distraction following a full-thickness osteotomy above the lingula; (2) unidirectional distraction applied to a sagittal ramus osteotomy according to Obwegeser; and (3) direct vertical augmentation with rigid fixation after sagittal osteotomy, supported by virtual surgical planning. Results: Vertical ramus augmentation of 15–25 mm was achieved in all cases. The first technique proved effective but technically demanding. The second approach improved vector control and device stability. The third, involving direct vertical augmentation with rigid fixation, simplified the procedure, reduced costs, and maintained bony contact for stable healing. Conclusions: Sagittal ramus osteotomy with direct stabilization represents a promising alternative to traditional distraction in selected patients, combining historical surgical principles with computer-assisted planning to achieve reproducible outcomes.

Surgical Techniques Development doi: 10.3390/std14040039

Authors: Fahim Kanani Majd Khalil Khalid Aotman Nir Messer Anastasiia Iserlis Narmin Zoabi

The operative management of complex abdominal wall hernias in nonagenarians entails significant risk, with emergent repair associated with mortality rates approaching 40%. We report the case of a functionally independent 90-year-old male presenting with a 48 h history of abdominal pain, obstipation, and emesis, consistent with an acute-on-chronic incarcerated ventral hernia. Despite advanced age and elevated perioperative risk, multidisciplinary evaluation supported surgical intervention. Laparotomy revealed a 22 × 18 cm hernia sac harboring an elongated sigmoid and approximately 150 cm of small intestine with signs of compromised perfusion secondary to an internal constriction band. Following adhesiolysis and decompression, bowel viability was restored, and a mesh repair was performed. The postoperative course was notable for transient respiratory failure necessitating reintubation and ICU management; however, full recovery was achieved by one-month follow-up. This case demonstrates that comprehensive assessment, rather than chronological age, should guide operative decision-making in nonagenarians and underscores the feasibility of complex abdominal wall reconstruction in this cohort when supported by multidisciplinary care and perioperative resources.

Surgical Techniques Development doi: 10.3390/std14040038

Authors: Alejandro Fernández-Gibello Gabriel Camuñas-Nieves Rubén Montes-Salas Felice Galluccio Alfonso Martínez-Nova

Background and objective: Heterotopic ossification (HO) of the plantar fascia is an exceptionally rare condition, with only a few cases mentioned in the literature. In comparison, calcification of the fascia occurs more frequently, especially in cases of chronic plantar fasciitis. Tenex™, a percutaneous ultrasonic tenotomy system initially designed for tendinopathy treatment, may offer a minimally invasive alternative to conventional surgery in selected cases of HO. So, the aim of this case report was to assess the improvement in the pain and in the foot function after a percutaneous ultrasonic debridement. Case presentation: We present the case of an 82-year-old male with a history of hypertension and hyperuricemia, who reported a two-year history of mechanical-type plantar pain described as “walking on a stone.” Radiographs and MRI confirmed heterotopic ossification at the central component of the plantar fascia. Pain and function were assessed with the Foot Function Index (FFI). Under ultrasound and fluoroscopic guidance, percutaneous ultrasonic debridement with Tenex™ was performed following tibial and sural nerve block and conscious sedation. The procedure was completed in 6 min and 29 s of cutting time. After surgery, the patient wore a protective shoe for 3 weeks, followed a relative rest protocol, and received NSAIDs for 5 days. At 48–72 h, the patient reported noticeable pain relief, with significant functional improvement after 1 month. Conclusions: This case shows how Tenex™ effectively treats plantar fascia HO. It led to quick symptom relief and functional recovery. The ultrasonic percutaneous debridement with Tenex™ was a safe and effective option compared to open surgery for this patient. However, more research is needed to set standardized treatment protocols and assess long-term results.

Surgical Techniques Development doi: 10.3390/std14040037

Authors: David W. Polly Kenneth J. Holton Paul Brian O. Soriano Jason J. Haselhuhn Kari Odland Jonathan N. Sembrano Christopher T. Martin Kristen E. Jones

Background/Objectives: A variety of techniques for pedicle screw placement exist. Efficiency claims have varied, but limited data are available to support or refute these claims. Our goal was to study our screw placement efficiency, reporting real-time screw placement using O-arm 3D navigation. Methods: We prospectively enrolled patients from July 2019 to February 2022 who were undergoing primary procedures involving thoracolumbar pedicle and pelvic screw placement with O-arm navigation. Screw time began at the first placement of the navigated probe/awl and ended once the navigated screwdriver was removed from the screw head. Confirmatory 3D scans were performed to assess all screw placements. Results: The real-time average to place pedicle screws was 2 min 9 s (SD ± 1 min 5 s); for pelvic screws, this was 3 min 36 s. Screw placement was slightly faster in pediatric patients (2 min 3 s) vs. adults (2 min 24 s), p < 0.001. Screw placement was faster in the thoracic spine (2 min 2 s) vs. the lumbosacral spine (2 min 22 s), p < 0.001. Screw placement was faster in adolescent idiopathic scoliosis (2 min 0 s) vs. all other diagnoses (2 min 24 s), p < 0.001. Screw placement performed by a single attending surgeon (2 min 24 s) was no different from dual-surgeon placement(2 min 13 s), p = 0.35. Conclusions: Our screw placement time is shorter than previously published estimates, and has a very high accuracy rate. While there are variations in how time is reported compared to the previous literature, our study serves as a benchmark for real-time screw placement for future studies. The use of navigation technology for pedicle and pelvic screw placement can be efficient.

Surgical Techniques Development doi: 10.3390/std14040036

Authors: Zhi-Kang Yao Li-Kai Kuo Wei-Ning Chang

Background: Displaced pediatric supracondylar humerus fractures (PSHFs) commonly require surgical treatment. Medial pin placement can cause iatrogenic ulnar nerve injury. This study presents a modified, step-by-step cross-pinning technique for PSHFs designed to avoid iatrogenic ulnar nerve injury. Methods: We retrospectively included patients with PSHF (Gartland types III or IV) who underwent closed reduction and percutaneous cross-pinning at our hospital from June 2014 to December 2024. Demographic data, fracture type, and preoperative and postoperative neurological deficits were recorded. Results: A total of 40 patients (16 boys and 24 girls) with a mean age of 6.6 ± 2.2 years (range, 2–14) were included. Most injuries were type III (35/40; 87.5%), whereas five patients (12.5%) had type IV injuries. Our technique resulted in no new cases of postoperative ulnar neuropathy. Conclusions: This study describes a modified medial pin insertion technique for unstable PSHFs. Careful attention to medial pin placement can minimize iatrogenic ulnar nerve injury.

Surgical Techniques Development doi: 10.3390/std14040035

Authors: Samuel F. Schaible Fabian C. Aregger Christoph E. Albers Lorin M. Benneker Moritz C. Deml

Background: Carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) vertebral-body replacements (VBRs) aim to mitigate subsidence, minimize imaging artifacts, and facilitate radiation planning while preserving fusion potential. We assessed the safety and efficacy of a novel modular, titanium-coated CFR-PEEK VBR (Kong®) for anterior column reconstruction (ACR) in the thoracolumbar spine. Primary question: Does the implant safely and effectively achieve and maintain kyphosis correction after ACR for trauma and neoplasms? Methods: A single-center retrospective case series was performed on 28 patients who underwent thoracolumbar ACR with the Kong® VBR for fractures or tumors (2020–2021). The primary outcome was the bi-segmental kyphotic angle (BKA). Secondary outcomes were screw loosening, cage height loss, fusion rate, subsidence, and tilting. Clinical status was recorded with Odom criteria, Karnofsky Performance Status (KPS), and AOSpine PROST. Results: Twenty-eight patients (mean age, 61 yr; 33% female; mean follow-up, 17.7 mts) were studied. Mean postoperative BKA correction was 16.5° (p = 0.006) and remained 14.5° at final follow-up (p = 0.008); loss of correction was 2.0° (p = 0.568). Subsidence, cage height, and sagittal tilt were unchanged. Fusion (Bridwell grade I/II) was observed in 95% on CT. One deep surgical-site infection occurred. At final follow-up, 91% of patients were graded “excellent” or “good” by Odom. KPS improved by 20 points (p = 0.031), and mean AOSpine PROST was 56.9. Conclusions: Single-center early results indicate that the modular titanium-coated CFR-PEEK VBR is a safe, effective adjunct for thoracolumbar ACR in trauma and neoplasm, providing durable kyphosis correction, mechanical stability and high fusion rates and grants for improved follow-up imaging quality.

Surgical Techniques Development doi: 10.3390/std14040034

Authors: Giorgia Cerretani Elisa Nardecchia Elena Asteggiano Alberto Colombo Davide Di Natale Luca Filipponi Nicola Rotolo

Background: Uniportal video-thoracoscopic lobectomy has improved postoperative outcomes in lung cancer patients. Thus, thoracic surgeons are increasingly required to learn this new approach. Methods: We evaluate the path of a single surgeon switching from triportal video-thoracoscopic lobectomy to the uniportal, using the cumulative sum (CUSUM) analysis, in a single center to assess the learning curve, enrolling 107 uniportal video-thoracoscopic lobectomies consecutively performed. CUSUM analysis detected how many uniportal video-thoracoscopies occur to obtain changes in mean operation time, among all procedures consecutively performed. CUSUM analysis identified the cut-off at the 67th procedure; this value was used to divide all patients into two groups: group A (first 67 patients, early phase) and group B (40 patients, experienced phase). Then, we analyze the perioperative outcomes between the two groups. Results: Gender characteristics of the two groups were statistically similar. Median operative time decreased significantly after the early phase [188 min (IQR: 151–236) vs. 170.5 (IQR: 134–202) (p-value = 0.02)], respectively. Similarly, during the second phase, the conversions rate decreased: [10 (15%) (group A) vs. 1 (2%) (group B) (p-value = 0.04)], as did the postoperative complications [28 cases (42%) vs. 9 cases (22%) (p-value = 0.04)] and the length of stay [6 days (IQR 5–9.5) vs. 5 days (IQR 4–8) (p-value = 0.04)], giving evidence of skills acquired in the second phase. Conclusions: CUSUM analysis identified 67 uniportal lobectomies, after which operative time, conversion rate, and perioperative complications significantly decreased; the moving average analysis further supports a progressive reduction in operative time. Despite prior multiportal video-thoracoscopic experience, switching to uniportal video-thoracoscopy requires a distinct learning process.

Surgical Techniques Development doi: 10.3390/std14030033

Authors: Jakub Kopeć Justyna Kukulska Magdalena Lewandowska

Background: Three-dimensional (3D) printing technology has rapidly emerged as a transformative tool in medicine, enabling the conversion of two-dimensional scans into highly accurate 3D models. This technology, especially when combined with artificial intelligence (AI) and advanced materials, offers numerous applications in surgical planning, simulation-based training, and patient-specific care. Methods: This review examines current literature and case studies on the use of 3D printing technology in various fields of medicine, especially in surgical specialties. Key applications include surgical planning, mock surgeries, biopsy guide creation, and customized implant fabrication across various surgical fields. Results: 3D printing is transforming surgery by enabling precise visualization of tumors and critical structures, significantly enhancing preoperative planning for conditions such as bone, soft tissue (e.g., neuroblastomas), renal, and maxillofacial tumors. In reconstruction surgeries, patient-specific 3D-printed implants ensure better anatomical compatibility, particularly in maxillofacial, neurosurgical, and vascular applications. Puncture guides improve procedural accuracy in interventions like percutaneous nephrolithotripsy. Detailed anatomical models aid in simulation-based training, increasing preparedness for complex procedures. Additionally, patient-specific implants and AI-integrated decision support systems are paving the way for more personalized and efficient surgical care. Conclusions: 3D printing technology, especially when combined with AI, is reshaping modern surgery by improving both accuracy, safety, and personalized healthcare. Its applications extend across multiple specialties, offering new possibilities in surgical planning, training, and patient-specific treatments. As AI and bioprinting continue to evolve, the potential for real-time applications, such as live-printed tissue implants and enhanced decision support, could drive the next phase of innovation in various fields.

Surgical Techniques Development doi: 10.3390/std14030032

Authors: Luigi Di Lorenzo Daniela Petracca David Iapaolo Annarita Passarella Sabrina Pecorelli Carmine D'Avanzo

Acquired tracheoesophageal fistulas (TEF) are a rare but severe complication in post-coma neurorehabilitation patients, particularly those requiring long-term tracheostomy and enteral nutrition. Early recognition and proper surgical management are critical to prevent life-threatening outcomes and functional deterioration. However, variability in clinical presentation and the lack of standardized multidisciplinary pathways often delay referral to thoracic surgeons. We present the case of a young patient with severe traumatic brain injury, prolonged tracheostomy, and percutaneous endoscopic gastrostomy (PEG), who developed a TEF due to tracheal ischemic injury. Clinical suspicion arose from indirect signs—such as recurrent aspiration and air in the PEG system—the diagnosis was confirmed by bronchoscopy and sagittal CT imaging. Surgical planning was carried out in close collaboration between rehabilitation physicians and thoracic surgeons, based on shared criteria involving ventilator weaning, nutritional status, and clinical stability. This case highlights the importance of a multidisciplinary, protocol-driven approach in managing TEF. Current literature supports timely but carefully selected surgical intervention, particularly in patients who are no longer ventilator-dependent, significantly reducing perioperative mortality (reported up to 60% in ventilated patients). Recent reviews advocate for standardized surgical techniques—such as single-stage repair with muscle flap interposition—and emphasize the value of early diagnosis using a combination of bronchoscopy, videofluoroscopy, and sagittal CT. We propose a structured clinical pathway integrating neurorehabilitation and thoracic surgery, aimed at optimizing timing and surgical outcomes in patients with acquired TEF. This model may serve as a foundation for future guidelines, improving both safety and efficiency in the multidisciplinary management of this complex complication.

Surgical Techniques Development doi: 10.3390/std14030031

Authors: Aviad Gravetz Vladimir Tennak Vadym Mezhybovsky Michael Gurevich Sigal Eisner Dana Bielopolski Fahim Kanani Eviatar Nesher

Background/Objectives: Double ureter kidney grafts raise concerns about increased urologic complications. Limited data exist on optimal surgical management due to small sample sizes in previous reports. This study evaluated outcomes using pantaloon ureteroneocystostomy in the largest reported cohort worldwide. Research Questions: Does pantaloon ureteroneocystostomy achieve comparable outcomes to single ureter transplants? Are long-term graft survival and function equivalent? Should this technique be adopted as standard practice? Methods: This retrospective matched cohort study involves 2210 kidney transplantations (2010–2024). Twenty-six double ureter grafts underwent pantaloon ureteroneocystostomy with dual stenting. Controls matched 1:1 for donor type, era, and recipient characteristics. The primary outcome was urologic complications. Statistical analysis included Kaplan–Meier survival curves and Mann–Whitney U tests. Results: Groups were well matched (median age: 51 vs. 52 years, 50% living donors each). Urologic complications occurred in 3.8% double ureter versus 7.7% control grafts (p = 1.000), markedly lower than 15.4% reported in recent literature. The single complication was early urinary leak, surgically repaired. No late strictures developed. The 5-year graft survival was 96.0% vs. 92.3% (p = 1.000). The final creatinine was comparable (1.25 vs. 1.28 mg/dL, p = 0.891). Conclusions: The pantaloon technique achieves superior outcomes in the largest reported double ureter cohort, with complication rates lower than previously published series. These findings support adopting this standardized approach globally to expand donor criteria while maintaining excellent outcomes.

Surgical Techniques Development doi: 10.3390/std14030030

Authors: Gianfilippo Caggiari Alessandro Zanzi Giuseppe Melis Fabrizio Quattrini Corrado Ciatti

Background: Proximal humerus fractures (PHFs) constitute a significant orthopedic challenge, particularly among the elderly, due to osteoporosis and comorbidities. While surgical intervention is often considered for complex fractures, non-surgical treatment (NST) has gained attention, especially during the COVID-19 pandemic, when surgical resources were limited. This study evaluates the functional outcomes of patients over 65 years old who underwent NST for PHFs during the pandemic. Methods: A retrospective analysis was conducted on patients presenting with 3- or 4-part PHFs at the Hospital Marino di Alghero (Italy) between 9 March 2020 and 18 May 2020. Inclusion criteria included age over 65, conservative management, and a minimum 30-month follow-up. Seven patients were evaluated through radiographic imaging and clinical assessments, including the Constant Shoulder Score (CSS), Oxford Shoulder Score (OSS), and Disabilities of the Arm, Shoulder, and Hand Score (DASH). Functional recovery was analyzed over a 48-month period. Results: The average CSS was 69.4 (SD: 22.3), OSS was 34 (SD: 14.6), and DASH was 27.9 (SD: 30.3), indicating moderate functional recovery. One patient required surgical fixation due to excessive displacement. Tuberosity union was observed in 85.7% of cases, and complications were minimal. NST allowed patients to recover shoulder function while avoiding surgical risks, particularly during the pandemic. Conclusions: NST proved to be a viable treatment for elderly patients with PHFs, yielding satisfactory functional outcomes with minimal complications. The pandemic highlighted the importance of conservative approaches in orthopedic management, emphasizing the need for individualized treatment decisions based on patient comorbidities and fracture characteristics.

Surgical Techniques Development doi: 10.3390/std14030029

Authors: Naohiro Shinohara Satoshi Nagano Hiromi Sasaki Noboru Taniguchi

Background: Benign bone tumors and tumor-like lesions in the proximal femur increase the risk of pathological fractures, often requiring surgical intervention. However, no consensus exists on the optimal treatment strategy. We developed a structured approach to guide the selection of implant types (compression hip screw [CHS] or intramedullary nail [IMN]) with or without bone grafting. This study aims to validate our treatment strategy through a retrospective analysis and a review of previous surgical outcomes. Methods: We sought to validate this strategy through a retrospective analysis of 16 patients (6 males and 10 females, mean age at surgery 37.4 years [range, 16–64 years]) with primary benign bone tumors or tumor-like conditions of the proximal femur, including the femoral head and neck. Curettage and synthetic or autologous bone graft was performed according to our treatment flowchart, utilizing either CHS or IMN for internal fixation. We compared the blood loss, operative time, time to full weight bearing, and perioperative complications between the CHS and IMN groups. Results: Blood loss did not significantly differ between the CHS and IMN groups (p = 0.11), but the operative time was significantly longer in the CHS group (p < 0.01). Two CHS cases experienced local recurrence, while no postoperative fractures were observed in either group. The median time to full weight bearing was 5 weeks, consistent with previous reports. No perioperative complications were noted. Conclusions: Our strategy achieved favorable clinical outcomes. IMN was selectively used in patients with non-aggressive benign tumors not involving the femoral head and neck, yielding good results with reduced surgical invasiveness, while in those patients with aggressive disease involving the head and neck, CHS was more appropriate. This approach may serve as a practical guide for surgical decision-making in benign proximal femoral bone tumors.

Surgical Techniques Development doi: 10.3390/std14030028

Authors: Romina-Marina Sima Liana Pleș Oana-Denisa Bălălău Mihaela Amza Ileana-Maria Conea Tina-Ioana Bunea Gabriel-Petre Gorecki Ancuța-Alina Constantin Cristian-Valentin Toma Mara-Mădălina Mihai Mircea-Octavian Poenaru

Urinary incontinence (UI) is a widespread worldwide gynecological pathology with a negative impact on women’s quality of life. We performed a narrative review and present a general, descriptive, and comprehensive perspective about surgical techniques for urinary incontinence in young women. Even though parity and vaginal births represent important risk factors for the occurrence of UI, it is also common among young women who are nulliparous. Lifestyle, obesity, smoking, alcohol consumption, and excessive stretching exercises can contribute to the occurrence of UI. Correct diagnosis and treatment may reduce the negative effects of UI on daily activities. Disease management varies depending on the three types of UI: stress, urge, and mixed. Conservative treatment involves lifestyle changes, pharmacological therapy, and pelvic floor muscle training. If symptoms persist, surgical techniques such as midurethral/suburethral slings, anterior colporrhaphy, and retropubic/laparoscopic colposuspension are necessary. Transvaginal tension-free vaginal tape obturator (TVT-O) is the most common surgical technique for the treatment of UI. Its effectiveness has been proven by reducing symptoms and improving quality of life. Alternative modern treatment methods are vaginal laser therapy, periurethral bulking agents injection, or local injection with autologous platelet-rich plasma. Surgical techniques for the treatment of UI are in continuous development and improvement considering the increased incidence of this pathology and the need of patients to improve symptoms and quality of life.

Surgical Techniques Development doi: 10.3390/std14030027

Authors: Enrique González Marcos Inés Almagro Vidal Rodrigo Arranz Pérez Julio Morillas Martinez Amalia Díaz Viudes Ana Rodríguez Martín Alberto José Gago Sánchez Carmen García De Leániz Daniela Rodriguez Marín

Background: Hip fractures represent a major clinical challenge, particularly in elderly and frail patients, where postoperative pain control must balance effective analgesia with motor preservation to facilitate early mobilization. Various regional anesthesia techniques are used in this setting, including the pericapsular nerve group (PENG) block, fascia iliaca compartment block (FICB), femoral nerve block (FNB), and quadratus lumborum block (QLB), yet optimal strategies remain debated. Objectives: To systematically review the efficacy, safety, and clinical applicability of major regional anesthesia techniques for pain management in hip fractures, including considerations of fracture type, surgical approach, and functional outcomes. Methods: A systematic literature search was conducted following PRISMA 2020 guidelines in PubMed, Scopus, Web of Science, and the virtual library of the Hospital Central de la Defensa “Gómez Ulla” up to March 2025. Inclusion criteria were RCTs, systematic reviews, and meta-analyses evaluating regional anesthesia for hip surgery in adults. Risk of bias in RCTs was assessed using RoB 2.0, and certainty of evidence was evaluated using the GRADE approach. Results: Twenty-nine studies were included, comprising RCTs, systematic reviews, and meta-analyses. PENG block demonstrated superior motor preservation and reduced opioid consumption compared to FICB and FNB, particularly in intracapsular fractures and anterior surgical approaches. FICB and combination strategies (PENG+LFCN or sciatic block) may provide broader analgesic coverage in extracapsular fractures or posterior approaches. The overall risk of bias across RCTs was predominantly low, and certainty of evidence ranged from moderate to high for key outcomes. No significant safety concerns were identified across techniques, although reporting of adverse events was inconsistent. Conclusions: PENG block appears to offer a favorable balance of analgesia and motor preservation in hip fracture surgery, particularly for intracapsular fractures. For extracapsular fractures or posterior approaches, combination strategies may enhance analgesic coverage. Selection of block technique should be tailored to fracture type, surgical approach, and patient-specific functional goals.

Surgical Techniques Development doi: 10.3390/std14030026

Authors: Francesca Bonomi Ettore Limido Yves Harder Ken Galetti Marco De Monti

Background: Autologous fat grafting is increasingly used in daily clinical practice across various surgical fields, including the treatment of chronic wounds, scars, burns, and non-healing perianal fistulas. Recently, some studies have shown that non-enteric cutaneous fistulas can also benefit from adipose tissue injections, but the efficacy remains unclear. This study aims to systematically review the literature on fat grafting in the context of non-enteric cutaneous fistulas and to assess treatment outcomes. Methods: A comprehensive search of the PubMed/Medline database was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines up to January 2024 without restrictions on the time period or the language of publication. Results: Seven studies meeting the inclusion criteria were analyzed, encompassing 13 patients with non-healing cutaneous fistulas treated with injections of autologous fat. The mean age of the patients was 58 ± 3 years, of which 85% had comorbidities. Fat grafting resulted in complete healing in 92% of the cases, with a mean fistula persistence of 158 days before treatment. Treatment protocols varied among patients, including preparation of the fistulous tract, fat processing techniques, and suturing of the fistulous orifice. Conclusions: The results highlight the potential of autologous fat grafting in promoting tissue regeneration and healing of non-enteric cutaneous fistulas. Standardized protocols are essential to confirm and optimize treatment efficacy and, eventually, improve patient outcomes. Further research with a larger sample size and standardization is needed to confirm fat graft efficacy.

Surgical Techniques Development doi: 10.3390/std14030025

Authors: Riccardo Nocini Valerio Arietti Luca Bianconi Luca Sacchetto

Endoscopic dacryocystorhinostomy (DCR) is a widely recognized and highly effective procedure. This surgical procedure is performed globally, with minimal modifications across different regions. Background/Objectives: The fundamental goal of DCR is to marsupialize the lacrimal sac into the nasal cavity, which helps eliminate epiphora (excessive tearing) and recurrent dacryocystitis (inflammation of the tear sac). With advancements in technology, new instruments are being developed to minimize risks and maximize efficacy, ultimately improving surgeon convenience, patient safety, and quality of life. One such innovation is piezosurgery, a method of bone cutting that utilizes ultrasound vibrations. Originally prevalent in oral and maxillofacial surgery, piezosurgery is now being applied in many clinical applications. Its primary advantages include the preservation of soft tissues, precise bone cutting, and the ability to work effectively in narrow spaces. Methods: This article outlines the standard technique used at our facility for performing endoscopic dacryocystorhinostomy (DCR) with a piezoelectric system. We describe the preoperative evaluation, intraoperative techniques, and postoperative care to present what we consider the standard procedure in our clinic. Results and Conclusions: Piezosurgery’s selective cutting prevents damage to surrounding soft tissues, making it theoretically advantageous in DCR by preserving tissue integrity. Additional case–control and multicenter studies are necessary to compare its outcomes with those of traditional osteotomy, particularly in relation to the potential increase in operative time.

Surgical Techniques Development doi: 10.3390/std14030024

Authors: Koh Kitagawa Shohei Asada Jun-ichi Hanatani Yuki Motokawa Yui Osaki Tomihiro Iwata Kosuke Kaji Akira Mitoro Hitoshi Yoshiji

Background/Objectives: Benign choledochojejunal anastomotic stricture (CJS) is a major late adverse event (AE) after choledochojejunostomy. An endoscopic method using balloon-assisted enteroscopy endoscopic retrograde cholangiopancreatography (BAE-ERCP) was recently developed for CJS. Methods: We retrospectively reviewed 45 patients (98 cases) who underwent BAE-ERCP for benign CJS. The primary endpoint was the success rate of ERCP. The secondary endpoints were AEs and the recurrence rate of benign CJS. Results: ERCP was successful in 36 patients (80%). Balloon dilation of the anastomosis was performed in all 36 patients in whom ERCP was successful, and temporary plastic stent (PS) placement was performed in 20 of these patients (55.6%). Three cases of PS migration and one case of portal vein thrombosis occurred as mild AEs. However, one case of intestinal perforation required emergency surgery for repair. In univariate analysis, proficiency in ERCP procedures (p = 0.019) and surgery at our hospital (p = 0.010) emerged as major factors affecting the procedural success. In univariate analysis, only the early onset of CJS within 400 days after choledochojejunostomy was extracted as a significant factor for the early recurrence of CJS after ERCP (p = 0.036). Conclusions: To ensure successful BAE-ERCP for CJS, it is essential to have proficiency in the ERCP and collect as much detailed information about prior surgery as possible before the procedure. Additionally, the risk of CJS recurrence might be high in patients in whom CJS develops early after surgery.

Surgical Techniques Development doi: 10.3390/std14030023

Authors: Francesco Roberto Evola Michele Vecchio Marco Vacante Giuseppe Evola

Background: There are no clear guidelines to support management decisions for patients with three-part fractures of the proximal humerus. The aim of the study is to identify the treatment used and to assess the functional and radiological outcomes at follow-up. Methods: A total of 126 patients were retrospectively included in the study and were divided into two groups based on the type of surgery: plate and nail group. We collected data on the patient’s sex, age, fracture type, surgery duration, fracture healing, initial and final neck–shaft angles, shoulder joint score, and complications. Results: A total of 69 patients received locking-plate internal fixation, while 77 patients underwent fixation with intramedullary nail. The two groups were comparable, with no significant differences observed in age, sex, or the number of patients. The average operation time for the locking-plate group (88.7 ± 10.5 min) was significantly longer compared to the intramedullary nail group (70.2 ± 8.3 min). The Constant–Murley score was 91.2 ± 6.7 (range 79–98) in the plate group and 90.5 ± 7.7 (range 80–98) in the nail group, with no statistically significant difference. Complications were observed in 16 patients (23.2%) of the locking-plate group and in 7 patients (9.1%) of the intramedullary nail group, with significant difference. Conclusions: Our assessment revealed no significant differences in fracture healing times, loss of reduction, or Constant–Murley scores between two groups. However, our results suggest that intramedullary nails have an advantage over locking plates in terms of reduced operation time and complications.

Surgical Techniques Development doi: 10.3390/std14030022

Authors: Joan Birbe Foraster

Facial reconstruction presents complex challenges due to the intricate nature of craniofacial anatomy and the necessity for individualized treatment. Conventional reconstructive methods—such as autologous bone grafts and prefabricated alloplastic implants—pose limitations, including donor site morbidity, implant rejection, and suboptimal aesthetic results. The emergence of 3D printing technology has introduced patient-specific implants (PSIs) that enhance anatomical fit, functional restoration, and biocompatibility. This review outlines the evolution of 3D-printed implants, key materials, computer-assisted design (CAD), and their applications across trauma, oncology, congenital conditions, and aesthetics. It also addresses current challenges and explores future directions, such as bioprinting, smart implants, and drug-eluting coatings.

Surgical Techniques Development doi: 10.3390/std14030021

Authors: Simon Keelan Mina Guirgis Benji Julien Peter J. Hewett Michael Talbot

Background: Teaching methodology has recently undergone significant evolution from traditional apprenticeship models as we adapt to ever-increasing rates of technological advancement. Big data, artificial intelligence, and machine learning are on the precipice of revolutionising all aspects of surgical practice, with far-reaching implications. Robotic platforms will increase in autonomy as machine learning rapidly becomes more sophisticated, and therefore training requirements will no longer slow innovation. Materials and Methods: A search of published studies discussing surgeon training and computer-enhanced simulation robotics and emerging technologies using MEDLINE, PubMed, EMBASE, Scopus, CRANE, CINAHL, and Web of Science was performed in January 2024. Online resources associated with proprietary technologies related to the subject matter were also utilised. Results: Following a review of 3209 articles, 91 of which were published, relevant articles on aspects of robotics-based computer-enhanced simulation, technologies, and education were included. Publications ranged from RCTs, cohort studies, meta-analysis, and systematic reviews. The content of eight medical technology-based websites was analysed and included in this review to ensure the most up-to-date information was analysed. Discussion: Surgeons should aim to be at the forefront of this revolution for the ultimate benefit of patients. Surgical exposure will no longer be due to incidental experiences. Rather, surgeons and trainees will have access to a complete database of simulated minimally invasive procedures, and procedural simulation certification will likely become a requisite from graduation to live operating to maintain rigorous patient safety standards. This review provides a comprehensive outline of the current and future status of surgical training in the robotic and digital era.

Surgical Techniques Development doi: 10.3390/std14030020

Authors: Kadhim Taqi Jaymie Walker Cecily Stockley Antoine Bouchard-Fortier Stefan Przybojewski Lloyd Mack

Background: Desmoid tumors (DTs) are rare, non-metastatic but locally aggressive connective tissue neoplasms. While standard treatments include surgery, radiation, and ablation, current guidelines advocate active surveillance unless tumors progress or symptoms worsen. Cryotherapy has shown promise in treating DTs; however, its application in rectus abdominis DTs has been limited due to proximity to critical intra-abdominal structures. Methods: This case series describes a novel approach involving laparoscopic-assisted cryoablation in three patients with rectus abdominis DTs. Laparoscopic visualization was employed to improve tumor localization and procedural safety during percutaneous cryoablation. Results: The average tumor size was 7.4 cm, and a mean of 14 cryoprobes were used per case. All patients experienced complete symptom resolution. One patient developed a complication—injury to the inferior epigastric artery—requiring embolization. Follow-up imaging at three months showed significant tumor shrinkage and necrosis in two patients. The third patient had increased lesion volume due to post-procedural hematoma, although radiological markers of cryoablation efficacy were present. Conclusions: Laparoscopic-assisted cryoablation appears to be a feasible and effective technique for treating rectus abdominis DTs, providing symptom relief and favorable early tumor response. Further studies are warranted to evaluate long-term outcomes and validate this approach in broader clinical settings.

Surgical Techniques Development doi: 10.3390/std14030019

Authors: Artem Rafaelian Sae-Yeon Won Thomas M. Freiman Florian Gessler Daniel Dubinski

Background and Importance: Chronic subdural hematoma (cSDH) is a common and complex neurosurgical problem, particularly in elderly patients. Revision surgery for chronic subdural hematoma can be challenging, particularly in cases with inhomogeneous, firm consistency and extensive adhesions. Clinical Presentation: In this article, we present our endless-loop craniotomy technique, which offers a novel approach to address these challenges by performing the wide, curved exposure of the subdural space utilizing the already-present burr hole. This technique allows for a wide, unobstructed view of the subdural space, enabling the access and evacuation of this chronic and often adhesive subdural hematoma. Conclusion: We believe that endless-loop craniotomy is a valuable addition to the neurosurgeon’s armamentarium for managing complex cases of revision surgery in chronic subdural hematomas.

Surgical Techniques Development doi: 10.3390/std14020018

Authors: Fahim Kanani Nir Messer Moshe Kamar Narmin Zoabi

Adult Bochdalek hernias represent a rare clinical entity that often presents diagnostic challenges due to their non-specific symptomatology. We report the case of a 42-year-old male who presented with acute abdominal pain and was found to have a left-sided Bochdalek hernia with strangulated small bowel. The patient underwent a successful laparoscopic repair using right lateral decubitus positioning, which facilitated optimal access to the diaphragmatic defect. The herniated bowel was reduced and found to be viable, and the defect was closed primarily with mesh reinforcement. This case highlights the importance of maintaining a high index of suspicion for diaphragmatic hernias in adults with vague abdominal and respiratory symptoms, the value of prompt imaging in establishing the diagnosis, and the efficacy of minimally invasive surgical techniques with innovative patient positioning for definitive management. The patient recovered well, with complete resolution of symptoms and no recurrence at the 4-year follow-up.

Surgical Techniques Development doi: 10.3390/std14020017

Authors: Silvia Juste-Alvarez Claudia Zaccaro Javier Gil-Moradillo Javier Romero-Otero Ignacio Moncada Alfredo Rodríguez-Antolín Borja Garcia-Gomez

Background/Objectives: The aim of this research was to compare perioperative outcomes, functional results, quality of life, and complications between robot-assisted simple prostatectomy (RASP) and holmium laser prostate enucleation (HoLEP) as minimally invasive techniques for treating benign prostatic hyperplasia (BPH) in large prostates (>150 cm3). Methods: This retrospective, multicenter, observational study (2007–2023) included patients with >150 cm3 prostate volumes who underwent either HoLEP or robot-assisted prostatectomy. Primary outcomes: success rate (complete enucleation, without transfusion or reintervention), good postoperative quality of life (IPSS 8th question score: 0–2), and continence at 6 months (no pads). Secondary outcomes: operative and catheterization time, hospital stay, enucleated gland weight, PSA reduction, Qmax improvement, and perioperative complications. Results: We included 95 HoLEP and 50 RASP patients with similar demographics and prostate volume (HoLEP: 187.72 cm3; RASP: 203.38 cm3). The success rate (HOLEP: 83.2%; RASP: 74%), continence rate (HoLEP: 85.1%; RASP: 86%), and quality of life (HoLEP: 83.2%; RASP 94%) were similar (p = 0.275, p = 1, and p = 0.075, respectively). HoLEP had a shorter operative time (97.58 vs. 122.4 min) and catheterization duration, with similar hospitalization duration (HoLEP: 3.46 days; RASP: 4.22 days). Although there was no significant difference in enucleated gland weight, HoLEP was more efficient (1.28 g/min vs. 1.06 g/min). Complication rates were similar (HOLEP: 15.5%; RASP: 26%; p = 0.12). Conclusions: Both RASP and HoLEP are safe for treating BPH in prostates >150 cm3, reporting similar success and continence rates and good quality of life after surgery. However, HoLEP achieved results with shorter operative time and catheterization duration.

Surgical Techniques Development doi: 10.3390/std14020016

Authors: Rodrigo Ferraz Galhego Tulio Martins Alvaro Cota Carvalho Marco Faria-Correa Raquel Nogueira

Purpose: Our aim is to offer an additional surgical option for patients with rectus diastasis, with or without associated abdominal wall hernias, through a minimally invasive approach with endoscopic surgical correction, presenting a new method for abdominal contouring via minimally invasive mini-abdominoplasty (MAMI). Ideas: According to the European Hernia Society (EHS) classification for RD, a widening greater than 2 cm of the linea alba is generally considered an indication for surgical correction. Recent approaches, such as MILA and SCOLA, are indicated for patients with a body mass index (BMI) of up to 28, based solely on height and weight. However, some authors consider this insufficient for determining the best surgical indication. Despite advances in skin retraction, there is still no evidence on how these devices affect postoperative outcomes when added to these techniques, as they depend on multiple factors such as age, skin firmness, number of passes, applied energy, etc. Consequently, even patients with a BMI of up to 28 may present significant flaccidity both above and below the umbilicus, as well as poor skin quality (thin, lax, with stretch marks), making SCOLA or MILA surgery alone unsuitable due to possible skin redundancy after surgery. Similarly, even patients with a high-positioned umbilicus, moderate flaccidity, and rectus diastasis, who in the past would have been strictly indicated for abdominoplasty, may benefit from mini-abdominoplasty with a minimally invasive approach (MAMI). Discussion: The main objective of this study is to provide another surgical option for patients who would otherwise be indicated for abdominoplasty and also for those undergoing MILA or SCOLA who still require minor skin removal to enhance the surgical result. Based on our experience, mini-abdominoplasty with a minimally invasive approach (MAMI) has the potential to serve a larger number of patients, since most present degrees of skin laxity that, even after using technologies, require skin excision. In addition to complementing the results, it reduces complications, results in smaller scars, allows a better correction and visualization of the diastasis, avoids periumbilical scars, and offers faster recovery compared to abdominoplasty. Conclusions: MAMI surgery has proven to be a safe and reproducible approach for selected women who wish to restore feminine body features after pregnancy and achieve a quick recovery. It yields satisfactory esthetic results due to the minimized scar, preservation of the natural umbilical scar, and improved surgical correction of rectus diastasis.

Surgical Techniques Development doi: 10.3390/std14020015

Authors: Eriko Hamada Thomaz Fleury Curado Kingman Strohl Yee-Hsee Hsieh

Background/Objectives: Upper airway patency is a key pathophysiological factor in obstructive sleep apnea (OSA). Research has primarily focused on the role of the genioglossus muscle in maintaining airway patency in OSA. However, hypoglossal nerve stimulation (HNS) therapy, which activates the genioglossus muscle, has been associated with poor outcomes in patients with lateral oropharyngeal collapse. The stylopharyngeus muscle is an upper airway dilator muscle that supports the lateral pharyngeal wall. Its role in maintaining upper airway patency and its effect on normal respiratory airflow is unclear. We hypothesize that bilateral transection of the stylopharyngeus muscles disrupts normal breathing. Currently, no animal model depicting lateral pharyngeal collapse has been reported. This study aims to introduce a novel rodent model with bilateral transection of the stylopharyngeus muscles to examine its effect on respiratory airflow and tracing. Methods: Adult male Sprague Dawley rats were divided into two groups: (1) bilateral stylopharyngeus muscle transection (n = 4) and (2) sham surgery (n = 2). Under anesthesia, the stylopharyngeus muscle was transected bilaterally in the transection group, while only exposure of the muscle was performed in the sham group. Respiratory airflow was measured using whole-body plethysmography before and after surgery, and airflow tracings were analyzed. Results: Significant alterations in respiratory airflow and tracings, particularly a flattening in inspiratory flow and sharp expiratory peaks, were observed on the first post-operative day in the transection group. The flattening of the inspiratory flow persisted over 3 days. No significant changes were noted in the sham group. Conclusions: Bilateral stylopharyngeus muscle transection alters normal airflow in a conscious rodent model, supporting the hypothesis that stylopharyngeus muscle plays a vital role in shaping respiratory airflow. The flattening of the inspiratory airflow is an indication of flow limitations through the upper airway patency due to the loss of stylopharyngeus function.

Surgical Techniques Development doi: 10.3390/std14020014

Authors: Joelington Dias Batista Gabrielly Santos Pereira Jobson Dias Batista Ludimila Dias Silva Josie Resende Torres da Silva Marcelo Lourenço da Silva

Background/Objectives: Pudendal neuralgia (PN) is a debilitating chronic pain condition resulting from injury, inflammation, or entrapment of the pudendal nerve. It significantly affects patients’ quality of life and poses challenges to treatment due to its complex etiology. Conventional therapies often provide limited or temporary relief. The impar ganglion block (IGB) has emerged as a potential intervention for managing refractory pelvic pain syndromes. This systematic review aimed to evaluate the clinical efficacy, safety, and applicability of IGB in treating patients with PN. Methods: This systematic review evaluates the efficacy and clinical applicability of IGBs in treating PN. Following PRISMA-P 2020 guidelines, a systematic search was conducted in PubMed/MEDLINE, Embase, LILACS, and Cochrane Library. Eligible studies included RCTs, observational studies, and case series assessing pain reduction and quality of life post-IGB. Non-neuropathic pelvic pain studies were excluded. The ROBVIS tool assessed the risk of bias. Results: Of 306 articles screened, 16 met eligibility criteria. Studies showed that the IGB provides significant pain relief, particularly for refractory cases. Image-guided techniques enhanced precision and reduced complications. Combination therapies with corticosteroids yielded longer-lasting analgesia. However, methodological inconsistencies and varied patient selection limited generalizability. Conclusions: The IGB is a minimally invasive, effective option for managing PN. Further high-quality RCTs are needed to standardize protocols, optimize patient selection, and evaluate long-term efficacy. A multidisciplinary approach remains essential.

Surgical Techniques Development doi: 10.3390/std14020013

Authors: Daniel Ilie Rotariu Bogdan Florin Iliescu Razvan Buga Bogdan Costachescu

Background: Midline cysts of the brain are comprised of the following entities, septum pellucidum cysts, cavum vergae cysts and velum interpositum cysts. These lesions are uncommon and often asymptomatic; nonetheless, certain clinical manifestations may be linked to midline cysts, including headaches, signs of elevated intracranial pressure, neurological deficits, or alterations in mental status. Controversy persists in the therapy of symptomatic cases, mostly due to the challenge of establishing a correlation between the symptomatology and the presence of the cyst. Case description: We present the case of a 64-year-old female known with type—1 neurofibromatosis that associated a midline cyst. The cyst was treated endoscopically, in the initial stage (single wall perforation) showed no clinical or imagistic improvement. The incriminated symptoms in these cases are caused not only by compression or obstruction of the CSF flow but also to a complex alteration of CSF dynamics, in this case the stoma was found permeable at the second surgery but there was no obvious communication on the preoperative evaluation by ventriculocisternostomy. A second surgery was performed, with bilateral perforation and subsequent improvement of symptomatology and decrease of cyst dimensions. A literature review is presented concerning clinical presentation, therapeutic options, and possible outcomes. Conclusions: Endoscopic fenestration is an efficacious method for treating midline cysts, with bilateral wall fenestration representing the standard practice. Understanding the anatomical and developmental specifics of the septal region, together with cerebrospinal fluid dynamics, is essential for effective treatment of this condition.

Surgical Techniques Development doi: 10.3390/std14020012

Authors: Naoki Imasato Shugo Yajima Ryo Andy Ogasawara Minoru Inoue Kohei Hirose Ken Sekiya Madoka Kataoka Yasukazu Nakanishi Hitoshi Masuda

Background/Objectives: Inguinal hernia (IH) is a common complication after robot-assisted radical prostatectomy (RARP), significantly impacting patients’ quality of life. This study aimed to evaluate whether peritoneal closure reduces the incidence of IH after RARP. Methods: A retrospective analysis was conducted on 772 patients who underwent transperitoneal RARP between April 2018 and March 2023. Patients with a history of IH surgery were excluded. Peritoneal closure, introduced in December 2021, was performed during the final steps of RARP in 144 patients. The incidence of IH was compared between patients with and without peritoneal closure. Multivariate analysis was performed to identify significant predictors of IH. Results: IH occurred in 73 patients (9.5%)—5 (3.5%) in the peritoneal closure group and 68 (10.8%) in the no peritoneal closure group. Multivariate analysis revealed that the absence of peritoneal closure (hazard ratio [HR] = 4.55, p = 0.04) and low body mass index (BMI < 23 kg/m2; HR = 2.51, p = 0.001) were significant predictors of IH. The two-year IH-free survival rate was 96.5% in the peritoneal closure group and 89.2% in the no peritoneal closure group. Conclusions: Peritoneal closure significantly reduces the incidence of IH after RARP. This simple and effective technique may serve as a valuable preventive measure against postoperative IH, potentially improving surgical outcomes and patient quality of life. Further studies are warranted to confirm these results in diverse patient populations.

Surgical Techniques Development doi: 10.3390/std14020011

Authors: Chiara Re Pietro Scilipoti Giuseppe Rosiello Nicola Leggio Giulio Avesani Rayan Matloob Andrea Salonia Francesco Montorsi Roberto Bertini

Background/Objectives: An 80-year-old man was admitted to our department after a salvage radical cystectomy for actinic cystitis due to radiotherapy for prostate cancer. He presented with a two-month history of feculent debris in the right stoma and deteriorated general conditions, after a long past medical history of recurrent complicated urinary infections. Methods: Computer tomography (CT) of the abdomen revealed a ureterocolic fistula along the right ureteral pelvic tract. A right percutaneous nephrostomy tube was placed. Due to multiple previous surgeries, several lines of intravenous antibiotic therapies and the overall condition of the patient, a conservative management was preferred. Results: A bovine serum albumin-glutaraldehyde (BioGlue®) adhesive was inoculated into the right ureter through the stoma to close the fistula. After 24 months, the patient remained asymptomatic with negative follow-up imaging. Conclusions: Given the uniqueness of the management of a ureterocolic fistula, this case offers insight into conservative treatment in frail patients not suitable for major surgery.

Surgical Techniques Development doi: 10.3390/std14020010

Authors: Ali Al Kaissi Alexander Gubin Sergey Ryabykh Vasileios Dougales Hamza Al Kaissi Susanne Gerit Kircher Franz Grill

Background: Facial features are the first basic sign of medical knowledge of children and adults with congenital malformations. Children born with multiple contractures almost always receive the misdiagnosis of arthrogryposis multiplex. Larsen syndrome can easily be diagnosed at birth via the proper interpretations of its characteristic facial features and multiple dislocations. Comprehensive clinical diagnosis can facilitate an orthopedic strategy for early treatment and can enhance the recognition of unreported craniocervical malformation complexes. Material and Methods: Six children (four boys and two girls, with ages ranging from a few months to 7 years old) were referred to our department for diagnosis and treatment. All children received their first misdiagnosis by the pediatricians as manifesting arthrogryposis multiplex congenita. The clinical phenotype was our first decisive tool for diagnosis. All children exhibited the classical phenotype of dish-like facies associated with multiple joint dislocations. Radiological phenotypic characteristics confirmed our clinical diagnosis of Larsen syndrome. Three children out of six showed unpleasant cervical spine deformities. The first child, a 2-year-old, became tetraplegic after minor trauma. One child presented with progressive rigid cervical kyphosis. The third child was a product of a first-relative marriage and was born with congenital tetraplegia. A genotype was carried out for confirmation. Results: Three children underwent open reduction for congenital hip and knee dislocations. One child underwent spinal fusion CO-C7 because of tetraplegia. A 3D-reformatted and reconstruction CT scan of the craniocervical junction showed two forms of unusual dys-segmentation, firstly along C2-3 effectively causing the development of acute-angle cervical kyphosis. Secondly, an infant with congenital tetraplegia showed a serious previously undescribed atlanto–axial malformation complex. Namely, atlanto–axial maldevelopment (dys-segmentation) of (C1/C2) was associated with hypoplasia of the anterior and the posterior rings of the atlas. Genetic tests of these children were compatible with the autosomal dominant type of Larsen syndrome and manifested a heterozygous mutation in FLNB mapped 3p14.3, encoding an actin-binding protein, filamin B. The child with congenital tetraplegia showed no mutations in FLNB, though his clinical and radiological phenotype and his family history of first-relative marriage were totally compatible with the diagnosis of the autosomal recessive type of Larsen syndrome. Conclusions: Our strategy was and still is based on a coherent clinical and radiological diagnosis, which is based on comprehensive clinical and radiological phenotypic characterizations. We implemented a 3D-reformatted CT scan to further understand the craniocervical junction pathology in three children. Strikingly, prenatal onset of lethal maldevelopment (dys-segmentation) of the atlanto–axial spine segments has been diagnosed in an infant with congenital tetraplagia. A less serious cervical spine malformation was detected in two children who presented with progressive acute-angle cervico and cervico-thoracic kyphosis. Our clinical strategy can form the basis for a thorough clinical assessment for infants and children born with multiple malformation complexes and can lead to recognition of novel understandings.

Surgical Techniques Development doi: 10.3390/std14020009

Authors: Halah Kutaish Vannary Tieng Philippe Matthias Tscholl

Aim: This study aims to assess the suitability of the Göttingen Mini-pig (G-MP) as a large animal model for preclinical research on articular cartilage treatment procedures. Additionally, this study compares the G-MP to the domestic pig (DP) regarding surgical anatomy, postoperative care, and the challenges associated with the follow-up period. Materials and methods: Six G-MPs and four DPs underwent a two-stage surgical procedure: first, cartilage was harvested using a superolateral approach, followed by cartilage implantation via a medial parapatellar tendon approach. Results: The superolateral approach exposed 11% (SD ± 5) of the trochlea in G-MPs and 20% in DPs. The medial parapatellar tendon approach exposed 63% (SD ± 4) of the trochlear surface and 34% (SD ± 13) of the medial femoral condyle in G-MPs, allowing for the creation of four 6 mm trochlear lesions and one medial condyle lesion in four out of six G-MPs and all DPs. Cartilage thickness was less than 1 mm in G-MPs, compared to over 2 mm in DPs. Weight gain was +4 kg/week in DPs and +0.2 kg/week in G-MPs. Conclusion: Overall, the G-MP proves to be a viable model for cartilage research, offering sufficient joint access via the dual approach, which allows for 4–5 lesions of 6 mm each. However, the thinner cartilage in G-MPs should be taken into account.

Surgical Techniques Development doi: 10.3390/std14010008

Authors: Jeremy Peabody Sukhdeep Jatana Kevin Verhoeff A. M. James Shapiro David L. Bigam Blaire Anderson Khaled Dajani

Background: Despite ongoing efforts to improve the pancreaticoduodenectomy technique and perioperative care, surgical site infection (SSI) remains a contributor to morbidity. Efforts to reduce SSI include the use of negative pressure wound therapy (NPWT), but studies and meta-analyses have been met with conflicting results. We aimed to provide an up-to-date large-scale cohort study to assess the impact of NPWT on SSIs. Methods: Utilizing the National Surgical Quality Improvement Program database, we included patients undergoing a pancreaticoduodenectomy between 2017 and 2021 and divided patients into the NPWT and non-NPWT cohorts. A bivariate analysis was performed to compare baseline characteristics and complication rates between the cohorts. Multivariate logistic regression analysis was performed to assess the independent effect of NPWT on 30-day serious complication, 30-day mortality, and the development of deep or superficial SSI. A priori sensitivity analyses were performed in high-risk and malignancy cohorts. Results: Of the 14,044 included patients, 1689 (12.0%) patients had a prophylactic NPWT device, while 12,355 (88.0%) did not. Patients were more likely to have NPWT if they had higher ASA scores, had diabetes, were dialysis-dependent, or had a hard pancreas, but they were less likely if they were a smoker, had steroid use, or had a bleeding disorder. Most complications occurred similarly between the two cohorts, including superficial and deep SSI, but NPWT patients had a longer length of stay (10.4 d vs. 9.5 d, p < 0.001) and higher organ space SSI (22.6% vs. 17.4%, p < 0.001). Following multivariable modeling to control for demographic differences, NPWT was not independently associated with a difference in likelihood of SSI (aOR 0.94, p = 0.691) or serious complications (aOR 0.958, p = 0.669). Furthermore, the sensitivity analyses of both high-risk and malignant subgroup also did not see an independent association of NPWT on the rate of SSI (aOR 0.98, p = 0.898 and 0.96, p = 0.788, respectively). Conclusion: NPWT is used infrequently and is not significantly associated with improved outcomes including in the high-risk or malignant subgroups based on multivariable analysis for surgical site infections nor did it improve the outcomes of 30-day serious complications in these subgroups. Considering this and other studies showing the limited benefit of NPWT in all-comers and in high-risk cohorts, it remains unclear whether NPWT offers benefits following PD.

Surgical Techniques Development doi: 10.3390/std14010007

Authors: Kirsten R. Carlaw Aizat Drahman Angelina Di Re

Background: Acute colonic pseudo-obstruction (ACP) is a life-threatening, rare condition of non-mechanical colon dilatation that can result in bowel ischaemia and perforation. The aetiology is relatively unknown but includes older age coupled with high comorbidity, decreased parasympathetic activity, certain medications, chemoradiotherapy and recent surgery. There are limited research data on ACP following reversal of ileostomy after ultra-low anterior resections (ULAR), thus this systematic review included cases from various types of bowel surgeries. Methods: A comprehensive literature search of relevant articles was conducted using the EMBASE, Medline, PubMed, Cochrane, and Scopus databases. Two cases of ACP following ileostomy reversal after ULAR for rectal cancer were also reported from the authors’ rural institution. This systematic review was conducted according to PRISMA 2020 guidelines. Results: A total of 522 studies were screened of which five case reports were included. Two case series (six patients) and the two patients from the authors’ rural institution developed ACP following reversal of ileostomy post-ULAR with potential causes being the > 6 months’ time from initial surgery to reversal causing prolonged colonic mucosal inflammation and reduced wall contractile strength. Anastomotic leak and chemoradiotherapy were other considerations. One of the rural patients developed right colon ischaemia and perforation needing urgent laparotomy, right hemicolectomy and formation of end ileostomy and mucous fistula. Conservative treatment included aperients, enemas, flatus tube, bedside or endoscopic decompression, and neostigmine. Conclusions: Early recognition is vital to treat ACP with medical therapy and decompression to prevent bowel ischaemia and perforation. Further research is needed to better characterise the aetiology, incidence and management strategies for this rare condition.

Surgical Techniques Development doi: 10.3390/std14010006

Authors: Yaman Alsabbagh Young Erben Houssam Farres

Background: Patients with no-option chronic limb-threatening ischemia (NoCLTI), lacking suitable distal arteries for conventional revascularization, face major limb amputation. The 1-year mortality rate after major amputation is 48.3%, increasing to 70.9% in 3 years. Open deep venous arterialization (DVA) offers a promising alternative for limb salvage, achievable through open, endovascular, or hybrid approaches. We aim to provide a comprehensive, step-by-step guide to performing open DVA in NoCLTI patients, addressing preoperative and postoperative considerations as well as the technical details of the procedure. Methods: Patient selection for open DVA focuses on individuals with NoCLTI at high risk for amputation. Preoperative assessments include evaluating risk factors, determining limb threat severity using the Wound, Ischemia, and foot Infection (WIfI) score, and mapping anatomical patterns via the Global Limb Anatomic Staging System (GLASS). The procedure involves identifying the target artery using Doppler ultrasound, performing microdissection to expose the artery and vein, ligating proximal vein branches, and creating a side-to-side anastomosis. Venous valves are disrupted with a valvulotome to allow antegrade flow. A proximal bypass graft may be applied if necessary. Results: Postoperatively, patients are monitored for 2–4 days with frequent Doppler assessments. Anticoagulation therapy begins with a heparin drip, transitioning to oral agents and/or dual antiplatelet therapy. Wound care includes deferred debridement for 2–4 weeks and may involve negative-pressure therapy. Follow-up involves weekly visits for the first month, and then at 3 months, and every 6 months thereafter, with surveillance using transcutaneous oxygen measurement, the toe–brachial index, and arterial duplex ultrasound. Conclusions: Open DVA represents a viable limb salvage option for patients with NoCLTI, potentially avoiding major amputations and improving quality of life. Success depends on careful patient selection, a meticulous surgical technique, and comprehensive postoperative care.

Surgical Techniques Development doi: 10.3390/std14010005

Authors: Javier Arredondo Montero María Rodríguez Ruiz

Introduction: Single-port video-assisted techniques, such as one-trocar-assisted pyeloplasty (OTAP) or Round-Traction-Assisted Pyeloplasty (RoTAP), have proven helpful for correcting congenital ureteropelvic junction obstruction (UPJO), especially in infants. Surgical Technique: This manuscript presents a technical variation based on the gloveport system that allows bimanual endocavitary dissection and protects the surgical wound during the procedure without increasing the cost or technical difficulty. Comment: This new technique, called gloveport-assisted retroperitoneal pyeloplasty (GARP), could be a valuable alternative for this pathology.

Surgical Techniques Development doi: 10.3390/std14010004

Authors: Traian Dumitrascu

Cytoreductive surgery in the context of a multidisciplinary approach, including adjuvant and neoadjuvant therapy (when indicated), aims ideally to obtain complete resection and represents the cornerstone for long-term survival in patients with advanced ovarian cancer (AOC). Positive lymph nodes are a relatively frequent appearance during cytoreductive surgery for AOC and a widely accepted negative prognostic factor for long-term survival. However, the impact of systematic pelvic and paraaortic lymph node dissection (SPALND) on early and long-term outcomes in patients with cytoreductive surgery for AOC and no suspected positive lymph nodes remains highly controversial. The paper aims to review the relevant scientific literature exploring the role of SPALND in patients with AOC, focusing on peer-reviewed papers published before and after the LION study’s data release. The LION trial represents the only level 1 evidence study providing no scientific arguments for the routine using SPALND in AOC as part of complete cytoreductive surgery in patients without clinical suspicion of positive lymph nodes. The LION trial changed the practice of surgeons regarding SPALND, and current essential guidelines do not recommend it as a routine. Furthermore, SPALND may increase morbidity rates of cytoreductive surgery for AOC and negatively impact the patient’s quality of life. A comprehensive pelvic and paraaortic lymph node assessment is mandatory before and during cytoreductive surgery for AOC for proper disease staging, adequate management, and long-term prognosis. Further research is needed to identify patients with AOC at high risk for lymph node metastases; this group might benefit from SPALND.

Surgical Techniques Development doi: 10.3390/std14010003

Authors: Abdelrahman Mohamed Mohamed Rahouma

Background: Bronchial sleeve resection with complex reconstruction is a rare and intricate surgical procedure, particularly when addressing metastatic carcinoid tumors. This case report details the surgical management of a young male with a typical carcinoid tumor metastasized to the hilar and subcarinal lymph nodes. Case Presentation: A 28-year-old medically fit male presented with cough and occasional blood-tinged sputum for 2 months that was diagnosed to be due to a typical carcinoid tumor involving the left main bronchus, with metastasis to the hilar and subcarinal lymph nodes. The patient underwent a left bronchial sleeve resection with complex reconstruction of the left lower lobe bronchus. The reconstructed bronchus was then anastomosed to the main bronchus followed by hilar and subcarinal lymph nodes dissection. The surgical approach aimed to preserve lung parenchyma while ensuring complete tumor resection. Postoperative recovery was uneventful, with the patient demonstrating satisfactory respiratory function. Histopathological examination confirmed the complete resection of the carcinoid tumor and metastatic lymph nodes (hilar and inter-lobar LN (positive 2/5) and subcarinal LN (positive 1/6)). The patient had no signs of recurrence at the 3-month follow-up. Conclusions: This case highlights the feasibility and effectiveness of bronchial sleeve resection with bronchial reconstruction in managing metastatic carcinoid tumors. The successful outcome underscores the importance of meticulous surgical planning and execution in achieving favorable results in complex thoracic surgeries.

Surgical Techniques Development doi: 10.3390/std14010002

Authors: Kunj C. Vyas Michael Abaskaron Mikaila Carpenter Taylor Manes Morgan Turnow Daniel T. DeGenova Benjamin C. Taylor

Background/Objectives: Popliteal artery injury is a rare but devastating complication of knee dislocations, significantly increasing the risk of limb ischemia, amputation, and poor functional outcomes if not promptly managed. This systematic review primarily evaluates the functional outcomes associated with this injury but also reviews current research on diagnostic modalities and treatment strategies to provide a comprehensive understanding of this severe orthopedic and vascular injury. Methods: A systematic search of PubMed, in accordance with PRISMA Guidelines, identified 144 studies, of which 13 full-text articles were assessed for eligibility after excluding 131 during the title and abstract screening. Six studies were excluded due to missing vascular injury or functional outcome data or being written in a foreign language, leaving seven studies for inclusion. These studies were predominantly retrospective, focusing on knee dislocations with popliteal artery injury and reporting validated functional outcomes such as the Lysholm and International Knee Documentation Committee (IKDC) scores. The data were synthesized narratively due to heterogeneity in the study designs, interventions, and outcome reporting. Results: Patients with vascular injuries consistently demonstrated poorer functional outcomes compared to those without, with mean or median Lysholm and IKDC scores consistently being lower than non-vascular injury patients. Increased BMI, delayed intervention, and multi-ligamentous injury were associated with worse outcomes, highlighting the importance of timely surgical management. Early repair and grafting techniques improved functional recovery, while diagnostic modalities such as Doppler ultrasound and CT angiography showed high sensitivity in detecting vascular injury. Complications included limb ischemia, prolonged rehabilitation, and amputation, often linked to delayed diagnosis. Conclusions: Knee dislocations with popliteal artery injury require rapid diagnosis and early surgical intervention to optimize functional outcomes and reduce complications. Standardized outcome measures and high-quality prospective research are needed to refine management strategies and address patient-specific factors like BMI.

Surgical Techniques Development doi: 10.3390/std14010001

Authors: David Maman Ofek Bar Yaniv Steinfeld Ali Sleiman Arsen Shpigelman Lior Ben Zvi Yaron Berkovich

Background: Anterior cervical discectomy and fusion (ACDF) is a common procedure for cervical radiculopathy and myelopathy. Severe obesity (BMI ≥ 40 or BMI ≥ 35 with comorbidities) is associated with increased perioperative risks. This study examines the impact of severe obesity on outcomes in patients undergoing single-level ACDF. Methods: Data from the Nationwide Inpatient Sample (2016–2019) were analyzed, including 85,585 patients who underwent single-level ACDF. Patients were classified as severely obese (n = 4935) or non-obese (n = 80,650). Outcomes such as length of stay, complications, and in-hospital mortality were compared using SPSS and MATLAB, with a significance level of p < 0.05. Results: Severely obese patients were younger (54 vs. 55.7 years, p < 0.001) and had more comorbidities like type 2 diabetes (38% vs. 17.8%, p < 0.001) and obstructive sleep apnea (31.1% vs. 9.5%, p < 0.001). They experienced longer hospital stays (1.92 vs. 1.65 days, p < 0.001) but similar in-hospital mortality (0.1%, p = 0.506). Severe obesity was linked to higher odds of complications, including increased risks of dehiscence (OR 8.2), respiratory failure (OR 6.5), myocardial infarction (OR 5.5), Horner syndrome (OR 4.7), pulmonary edema (OR 4.5), and dural tears (OR 4.1). Risks of acute kidney injury, pulmonary embolism, and dysphonia were also elevated in severely obese patients. Conclusion: Severe obesity is associated with higher complication rates and longer hospital stays following ACDF. Tailored perioperative management is essential to mitigate these risks and improve outcomes in this high-risk population.

Surgical Techniques Development doi: 10.3390/std13040033

Authors: Andrea Morini Massimiliano Fabozzi Magda Zanelli Francesca Sanguedolce Andrea Palicelli Alfredo Annicchiarico Candida Bonelli Maurizio Zizzo

Background/Objectives: Transanal irrigation (TAI) has been recognized as a safe and effective treatment for neurological bowel dysfunction, chronic constipation or fecal incontinence and has also been proposed for patients with low anterior resection syndrome (LARS). The aim of the present systematic review was to evaluate the feasibility and effectiveness of TAI in patients with significant LARS symptoms. Methods: We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and guidelines in addition to the Cochrane Handbook for Systematic Reviews of Interventions. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023436839). The risk of bias was assessed using a modified version of the Downs and Black checklist. The main outcome was improvement in low anterior resection syndrome after TAI assessed by change in LARS score. Results: After an initial screening of 3703 studies, 9 were included and underwent qualitative synthesis (among them, 3 were randomized clinical trials). All studies recorded an improvement in LARS score following TAI procedure and almost all studies showed an improvement in other bowel function outcomes (Memorial Sloan Kettering Cancer Center Bowel Function Instrument (MSKCC BFI, ), Cleveland Clinic Incontinence Score (CCIS), visual analog scale (VAS), Cleveland Clinic Florida Fecal Incontinence Score (CCFFIS), fecal incontinence score (FI score), Obstructed Defecation Syndrome (ODS) score) and quality of life (QoL) scores. The discontinuation rate ranged from 0% to 41%. The rate of adverse events was high (from 0 to 93%); moreover, no uniformity was found in the various protocols used among the different studies. Conclusions: The results of this review show that TAI is effective in the treatment of LARS, improving the LARS score, the other bowel function outcomes and the QoL scores. The absence of a treatment protocol validated by the scientific community is reflected in the high disparity in terms of adverse events and discontinuation of therapy, in addition to representing an intrinsic limitation to the study itself.

Surgical Techniques Development doi: 10.3390/std13040032

Authors: Morgan Turnow Trent Davis Thomas Seebacher Grant Chudik Taylor Manes Hunter Pharis Daniel Degenova Sanjay Mehta

Background: Femoral head fractures with osteochondral defects are rare injuries often resulting from traumatic hip dislocations. These injuries create a significant risk for post-traumatic osteoarthritis. Various surgical methods for repair have been utilized to restore these osteochondral defects, including mosaicplasty, autologous cartilage implantation, osteochondral allograft transplant (OAT), and demineralized bone matrix (DBM). Methods: We present a case of a 21-year-old male who sustained a fracture-dislocation of the left femoral head with impaction of the weight-bearing surface due to a motor vehicle collision. Due to the patient’s relatively young age, OAT plugs from a fresh-frozen proximal humerus with DBM supplementation during fracture fragment fixation were chosen to reduce the likelihood of post-traumatic arthritis. Results: The patient regained subjective function and full strength on exam with no pain at 2 years postoperatively. Conclusions: We propose that a proximal humerus allograft is a suitable alternative in an urgent setting when a femoral head allograft is not available.

Surgical Techniques Development doi: 10.3390/std13040031

Authors: Mario Suárez-Ortiz Sofía Mora-Pardo Miguel López-Vigil Francisco Muñoz-Piqueras Alfonso Martínez-Nova

Introduction: Metatarsalgia is a very common pathology in podiatric consultations, whose main aetiological factor is biomechanical alterations. Given the failure of conservative treatments, minimally invasive osteotomies of the distal metatarsal are becoming more popular, providing comparable results to open surgical techniques and with a lower rate of complications. Objectives: To determine clinical improvement and patient satisfaction after minimally invasive distal metatarsal osteotomy (DMMO) as a surgical treatment for central metatarsalgia at present. Methodology: The databases used for this systematic review were PubMed, Scielo, Cochrane Library, WOS and Scopus. We included articles that studied the efficacy of DMMO for primary metatarsalgia and excluded studies whose patients had more than one pathology or used other surgical techniques. Results: We identified 10 articles, 5 prospective studies, 4 retrospective studies and 1 cross-sectional, non-randomized, analytical study published between 2015 and 2021. The total number of subjects was 366, with a mean age of 61 years. The majority of subjects were women. They presented with symptomatology compatible with primary metatarsalgia for a minimum of 6 months and had failed conservative treatment. Conclusions: DMMO osteotomies for central metatarsals offer excellent post-surgical results for the treatment of central metatarsalgia in the assessment scales (AOFAS, MOXFQ etc.) of the articles analyzed and therefore an evident clinical improvement with benefits in terms of MTF mobility and reduction of surgical time, as well as a high degree of satisfaction in the patients who received this intervention that can be considered as excellent.

Surgical Techniques Development doi: 10.3390/std13040030

Authors: Alessandro Pisano Gaetano Caruso

Background/Objectives: Acute ruptures of the Achilles Tendon (AT) are common injuries in the active population, in particular among men aged 30 to 50. Full functional recovery after this kind of injury is long and challenging and nowadays there is no universal “gold standard” strategy when dealing with them. Methods: When it comes to surgical treatment, various techniques have been described: in case of a typical lesion at the midportion of the tendon (which is the most common type), the basic principle of surgical repair is the end-to-end suture of the tendon stumps. The AT (“calcaneal tendon” according to the International Anatomical Terminology) is the strongest tendon of the human body, it is the conjunct tendon of the two Gastrocnemii Muscles and the Soleus Muscle and has a well-recognizable twisted structure: the subtendon from the Medial Head of the Gastrocnemius attaches postero-laterally on the calcaneal tendon footprint, the subtendon from the Lateral Head of the Gastrocnemius attaches antero-laterally and the subtendon from the Soleus attaches medially, therefore creating a 90° twist of the tendon structure. Results: the twisted structure of the human AT is of central importance to its biomechanics, since it gives the tendon a higher resistance to deformation and concurs in supination of the subtalar joint during gait. Conclusions: given the abovementioned anatomical and biomechanical premises, we believe that the restoration of the subtendons anatomy can lead to a better functional recovery of the Triceps Surae—Achilles Tendon complex, therefore we recently decided to adopt for open surgical repair the Direct Anatomical Reconstruction of the Achilles Tendon, which we describe in the present article.

Surgical Techniques Development doi: 10.3390/std13040029

Authors: Gianpaolo Faini Alice Ferrari Lena Hirtler Lorena Giugno Sergio Arleo Barbara Buffoli

Background: A microsurgical auricular flap represents a single-step technique for the reconstruction of full-thickness defects of the ala nasi. To achieve the best surgical outcomes, it is essential to have an exhaustive knowledge of the vascular network to improve the management of the surgical flap. This study aimed to provide an anatomical and surgical guide for a well-designed reconstruction of the ala nasi using a free preauricular flap. Methods: In this study, three fresh-frozen and two formalin-fixed human head specimens injected with red silicone rubber to enhance the arterial facial system were used. The reconstruction of the full-thickness defect of the ala nasi was performed using a microsurgical auricular flap technique, with the dimensions of the ala nasi and the preauricular flap duly noted. In addition, anatomical dissections were conducted, during which the positions and diameters of the main donor and recipient vessels were measured. Results: A presurgical evaluation was performed to define the flap design. A comparison of the shape and mean dimensions of the ala nasi defect (height 9.66 ± 1.40 mm; thickness 3.52 ± 0.53 mm) and the preauricular flap (height 8.50 ± 2.68 mm; thickness 3.92 ± 1.29 mm) indicated that this flap was an optimal option for the reconstruction of the ala nasi. The surgical procedure involved the full-thickness removal of the ala nasi, and the harvesting and insertion of the preauricular flap. The anatomical measurements demonstrated that the facial artery and veins were the optimal recipient vessels, with a diameter of >1 mm (2.08 ± 0.56 and 2.85 ± 0.74 mm), suitable for anastomosis with the superficial temporal artery and vein (1.86 ± 0.58 and 1.66 ± 0.15 mm). In addition, the postsurgical evaluations indicated a slight mean difference in the thickness (1.14 ± 0.65 mm) and height (1.68 ± 1.18 mm) between the ala nasi and helix and a satisfactory VAS score (7.9 ± 0.57). Conclusions: Our surgical and anatomical data provide compelling evidence in favour of free preauricular flap reconstructions of the ala nasi. This procedure allows for the correct choice of recipient vessels and the creation of a well-designed surgical flap.

Surgical Techniques Development doi: 10.3390/std13040028

Authors: Yuan-Cheng Liu Peir-Rong Chen

Background/Objectives: Temporary artery ligation or compression is commonly used to reduce intraoperative blood loss in various surgeries, including uterine procedures. In head and neck surgery, the external carotid artery (ECA) typically branches into eight vessels, supplying most of the head and neck except for the brain. Severe and uncontrolled bleeding can occur if these branches are inadvertently damaged during surgery. However, limited research exists on temporary arterial ligation during head and neck surgeries. This study aimed to evaluate the effects of temporary ECA restriction and internal maxillary artery (IMA) ligation on minimizing intraoperative blood loss during head and neck surgery. Methods: This study involved 25 patients with terminal-stage maxillary tumors who underwent total maxillectomy. The effectiveness of IMA ligation and ECA restriction using a Rummel tourniquet in controlling intraoperative bleeding was compared. Results: The average blood loss was significantly lower in the ECA restriction (467 mL) and IMA ligation (461 mL) groups than in the control group (794 mL). However, no significant difference was observed between the IMA ligation and ECA restriction methods. Conclusions: Overall, our results suggest that either method is effective; however, ECA restriction is preferred for tumors involving the infratemporal fossa.

Surgical Techniques Development doi: 10.3390/std13040027

Authors: Benjamin F. B. Mayer Sebastian Bodenstedt Patrick Mietkowski Rudolf Rempel Lena M. Schulte Stefanie Speidel Hannes G. Kenngott Karl F. Kowalewski

(1) Background: The aim of this study was to investigate potential translational factors for optical 3D reconstruction in an in vivo setting using a newly developed computerized bowel length measurement system (BMS) as a real-time application. (2) Methods: The BMS was evaluated in an in vivo porcine experiment for the influence of light source power (Watt), laparoscope-to-bowel distance (cm), bowel rotation, image background, and surgical objects in the image. Endpoints were robustness, calculated as success rate (SR) in percent, and accuracy, defined as relative error (RE) in percent of BMS measurement result to ground truth. (3) Results: A total of 1992 bowel measurements were performed on n = 7 pigs using the BMS. Bowel measurements were robust and accurate regardless of light source power, at a laparoscope-to-bowel distance of 5 cm (SR 100%, RE 18 ± 38.5%), when the small bowel was aligned horizontally (SR 100%, RE 7.3 ± 36.2%) or in the image background (SR 100%, RE 15.2 ± 23.4%), and when no additional instruments were in the image. (4) Conclusions: Applications based on optical 3D reconstruction are feasible for intraoperative use and could enable quantitative laparoscopy.

Surgical Techniques Development doi: 10.3390/std13040026

Authors: Hadar Gan-Or David Maman Assil Mahamid Binyamin Finkel Loai Ahmad Takrori Eyal Behrbalk Yaron Berkovich

Introduction: Femoral neck fractures pose significant health risks, particularly in the elderly population, leading to mortality, morbidity, and decreased quality of life. Surgery is the preferred treatment to restore function and alleviate pain, with options including total hip arthroplasty (THA) and hemiarthroplasty (HA). However, clinical guidelines for selecting surgical procedures remain heterogeneous, prompting the need for further investigation into treatment trends and influencing factors. Methods: Data from the NIS database spanning 2016–2019 were analyzed, focusing on patients diagnosed with intracapsular femoral neck fractures and undergoing THA or HA as primary in-hospital surgeries. Advanced statistical analyses using SPSS and MATLAB were conducted to identify trends and factors influencing surgical choices. Results: Comorbidity profiles varied significantly between HA and THA patients, with specific conditions such as Alzheimer’s disease showing higher prevalence in HA patients. Demographic differences included a higher proportion of females and Medicare-insured individuals in the HA group. Racial disparities were observed, with differences in surgical preferences among various ethnic groups. THA adoption gradually increased over the study period, indicating a shift in surgical priorities. Additionally, THA patients tended to be younger on average compared with HA patients. Conclusions: This study highlights evolving trends in surgical management for femoral neck fractures and identifies factors influencing treatment decisions in our cohort. Understanding these trends and disparities is crucial for optimizing patient care and informing future clinical guidelines. Further research should focus on assessing different surgical approaches’ long-term outcomes and cost-effectiveness.

Surgical Techniques Development doi: 10.3390/std13040025

Authors: Giovanni Federico Nicoletti Francesca Graziano Federica Paolini Roberta Costanzo Manikon Poullay Silven Massimo Furnari Domenico Gerardo Iacopino Rosario Maugeri Bipin Chaurasia Gianluca Ferini Giuseppe Emmanuele Umana Gianluca Scalia

Background/Objectives: The craniovertebral junction (CVJ) poses unique challenges in the surgical management of intradural extramedullary (IDEM) tumors due to its complex anatomy and proximity to critical neurovascular structures. This study presents a comprehensive review of a single center’s experience over three years in managing IDEM tumors at the CVJ, emphasizing a novel approach to dural opening aimed at improving surgical access and patient outcomes. Materials and Methods: A retrospective analysis was conducted on patients with confirmed IDEM tumors involving the CVJ who underwent surgical intervention between January 2019 and December 2021 at the “ARNAS Garibaldi” Neurosurgical Department. The surgical technique involved a posterior midline approach with a modified dural opening technique, facilitating lateral dural incisions based on tumor location and size. Clinical, radiological, and surgical data were collected and analyzed, including patient demographics, tumor characteristics, surgical details, complications, and postoperative outcomes. Results: Eight patients (mean age: 53.87 ± 8.9 years) with diverse IDEM tumors (meningiomas, schwannomas, neurofibromas) at various locations, from the foramen magnum to the C2 vertebra, were included. Common symptoms included paresthesia (62.5%) and neck/head pain (62.5%). The modified dural opening technique enabled complete tumor resection in all cases, demonstrating favorable postoperative outcomes with no significant postoperative complications except for one case with CSF leak. Conclusions: This study highlights the complexity of managing IDEM tumors at the CVJ and introduces a novel modified dural opening technique aimed at optimizing surgical access while minimizing spinal cord retraction. Early outcomes suggest improved postoperative neurological status and reduced surgical complications. However, careful patient selection and meticulous technique are crucial. Further studies are warranted to validate the safety and efficacy of this approach, fostering advancements in the surgical management of IDEM tumors at the CVJ.

Surgical Techniques Development doi: 10.3390/std13030024

Authors: Kyle M. Ockerman Nhan Trieu Sabrina H. Han Markos Mardourian Lisa Spiguel Kalyan Dadireddy Sarah Sorice Virk

Introduction: Mastectomy skin necrosis (MSN) is a common complication occurring in up to 50% of patients. In patients with risk factors for poor wound healing such as immunosuppression, prior radiotherapy (XRT), and high body mass index (BMI > 30.0), this number is even higher. MSN can lead to infection, loss of reconstruction, poorer aesthetics, and most ominously, delay in adjuvant cancer therapy. Instead of forgoing reconstruction in these patients, adjunctive therapies to optimize wound healing are necessary. The purpose of this study is to introduce the use of cryopreserved umbilical tissue (vCUT) as an adjunct therapy for high-risk-wound-healing immediate breast reconstruction (IBR) patients. Methods: All patients who underwent breast reconstruction with vCUT as an adjunctive therapy were identified and retrospectively analyzed. Results: Seven patients who underwent breast reconstruction with vCUT placement were identified. These patients had risk factors for delayed healing, such as obesity, immunosuppression, and/or prior XRT. The mean post-operative follow-up was 252 days (range 183–287). Four out of seven patients demonstrated post-operative complications: two out of seven developed seromas, two out of seven developed wound dehiscence, two out of seven developed infection, two out of seven developed MSN, and two out of seven lost their reconstruction. Conclusion: As undergoing IBR leads to improved mental health and superior aesthetic outcomes, efforts to expand current indications for safe IBR to traditionally poorer reconstructive candidates are imperative. The results of this case series demonstrate vCUT as a promising novel adjunctive tool in the reconstructive surgeons’ armamentarium in managing the less ideal reconstructive breast candidate.

Surgical Techniques Development doi: 10.3390/std13030023

Authors: Mihai-Daniel Dinu Bashar Haj Hamoud Mihaela Amza Romina-Marina Sima Ileana-Maria Conea Gabriel-Petre Gorecki Liana Pleș

Pelvic inflammatory disease is an infectious condition affecting women’s upper genital tract, including the uterus, fallopian tubes, and ovaries. It primarily arises from an infection that spreads upward from the lower genital area. The relationship between chronic pelvic pain and coexisting conditions is a key focus in its diagnosis and treatment. This type of pain is also considered a form of reflex dystrophy, involving both neurological and psychological components, the first line treatment consists in antibiotherapy. For patients with complex or severe pelvic abscesses, surgical intervention may be considered in selected cases. The primary surgical techniques employed are open and laparoscopic surgery, both aimed for abscess removal. MRI or Doppler ultrasonography may be employed when there is a suspicion of adnexal torsion, adenomyosis or deep pelvic endometriosis, especially if the ultrasound results are unclear or inconclusive Laparoscopic surgery has increasingly become favored by both healthcare professionals and patients. Moreover, laparoscopy has emerged as the most valuable tool for diagnosing chronic pelvic pain. The approach to treating pelvic abscesses in women of reproductive age depends greatly on clinical assessments, individual patient factors, and the desire to preserve fertility. However, laparoscopy may present technical difficulties in patients with severe pelvic abscesses, particularly those with extensive adhesions or a closed-off pelvic area, requiring advanced surgical expertise. Women with associated conditions such as endometriosis often experience a more severe form of pelvic inflammatory disease, which is less responsive to antibiotics and more frequently requires surgical resolution. The surgical treatment should be performed individualized to the clinical condition of the patient and the time of intervention must be carefully chosen.

Surgical Techniques Development doi: 10.3390/std13030022

Authors: Khrystyna Kuzmych Carolina Sassorossi Dania Nachira Maria Teresa Congedo Stefano Margaritora Elisa Meacci

Background: In the landscape of thoracic surgery, innovation continually drives progress, offering novel approaches to address complex pathologies while prioritizing patient well-being. Dual-port robotic-assisted thoracic surgery (DRATS) represents a new frontier in this evolution. In this report, we describe our experience with the fully dual-port robotic-assisted thoracic surgery (F-DRATS) approach for segmentectomy with the indocyanine green intersegmental plane identification. Methods: We define as F-DRATS the robotic thoracic surgery performed by two intercostal incisions without rib spreading, using the robotic camera, robotic dissecting instruments, and exclusively robotic staplers. We herein describe our F-DRATS approach in lingulectomy and lymphadenectomy of stations 5, 6, 7, and 10 using the da Vinci Surgical System. Results: The patient’s postoperative course was uneventful with the chest tube removed on the second postoperative day. The final pathological analysis confirmed a low-grade malignant potential adenocarcinoma, with a main diameter of 1.1 cm, at 3 cm from the lung margins. Conclusions: This is the first description in the literature of a F-DRATS lingulectomy with ICG intersegmental plane identification.

Surgical Techniques Development doi: 10.3390/std13030021

Authors: Dean C. Perfetti Stanley Kisinde Theodore A. Belanger Isador H. Lieberman

The spine community is continuously adding to its armamentarium of intraoperative techniques for visualization and instrumentation of the spine. Recently, three-dimensional printed spine models were introduced for use in preoperative planning, surgical simulation, and intraoperative guidance. We present a 14-year old African male with congenital kyphoscoliosis, small stature, an obvious gibbus deformity and coronal imbalance, who underwent a three-staged posterior surgical correction procedure, during which a 3D-printed spine biomodel was utilized for better appreciation of his complex spinal deformity patho-anatomy. During the first stage of the procedure, he developed diminished lower extremity motor strength bilaterally and bowel/bladder control, but, following his third stage procedure and with focused rehabilitation efforts, he has regained full control of his bowel and bladder function, and is able to ambulate and perform activities of daily living independently, albeit still requiring intermittent walking support with a single forearm crutch due to residual left leg weakness. The 3D spine biomodel functioned successfully as a valuable tool and surrogate anatomic blueprint for the surgeons, enabling adequate appreciation of the complex bony anatomy which could not be easily resolved on the conventionally available imaging modalities, intraoperative navigation or robotic platform. Theoretically, up to $2900 USD in savings, translated from the mean estimated time saved per procedure with the use 3D-printed spine models has been proposed in some studies. Therefore, 3D-printed spine models have utility in complex spinal deformity correction surgery.

Surgical Techniques Development doi: 10.3390/std13030020

Authors: Riccardo Orlandi Lorenzo Gherzi Michele Ferrari Giovanni Mattioni Marco Alifano Alessandro Pardolesi

Background: anatomic lung segmentectomies allow accurate resection of pulmonary lesions, maximizing healthy tissue preservation, and reducing unnecessary loss of lung function. In this setting, accurate preoperative planning is crucial. We present our early experience, detailing the successful use of 3D-CT models in tailoring therapeutic strategies for three patients undergoing complex anatomical lung resections due to neoplastic diseases. Case Presentation: (1) 60-year-old male patient with significant pulmonary functional impairment underwent successful right lower lobe bi-segmentectomy (S7–S8) for carcinoid, stage IA1. (2) 65-year-old female patient with previous left lung resection and functional impairment underwent uneventful right upper lobe bi-segmentectomy (S1–S2) for double lung adenocarcinoma, stage IIb. (3) 67-year-old male with previous ipsilateral lung resection underwent left lower lobe segmentectomy (S8) for metastatic colic adenocarcinoma without any complications. Conclusion: 3D-CT imaging, particularly through VPTM platform, enhances the safety and precision of complex lung segmentectomy, providing a valuable surgical map for improved outcomes.

Surgical Techniques Development doi: 10.3390/std13030019

Authors: Jure Pavešić Mislav Jelić Stjepan Dokuzović Sathish Muthu Ana Miletić Stjepan Ivandić Vide Bilić Stipe Ćorluka

Background and Objectives: Thoracolumbar fracture–dislocations (AO type C) are rare injuries that occur due to high-energy trauma, and the result is translational and rotational instability of the spinal column and neurological impairment. Several reduction maneuvers have thus far been published, each of which can be of use in certain specific situations. We developed a modification to the previously described reduction technique. Materials and Methods: This is a case study on the management of thoracic AO type C fracture–dislocations managed with a modified reduction technique. The success of the reduction and intraoperative iatrogenic complications such as dural tear and screw pull out were the outcomes analyzed. Results: A total of four cases were successfully reduced with this described reduction technique. We did not note any complications such as a dural tear or screw failure with this modified reduction technique. Conclusions: A modification to the reduction technique employed in the management of thoracic fracture–dislocations resulted in a successful reduction without the risk of iatrogenic complications due to the reduction maneuver.

Surgical Techniques Development doi: 10.3390/std13030018

Authors: Itay Ashkenazi Nissan Amzallag Shai Factor Nadav Graif Or Shaked Yaniv Warschawski Tomer Ben-Tov Amal Khoury

Background: An association between increased postoperative glycemic variability (GV) and inferior postoperative outcomes following hip arthroplasty procedures has been previously reported. However, the utilization of the GV to project surgical outcomes following the fixation of hip fractures has not been well established. The aim of this study is to assess the association between the postoperative GV of patients with diabetes mellitus (DM) and surgical outcomes following the fixation of a hip fracture. Methods: This is a retrospective analysis of 3117 consecutive cases of patients who underwent the fixation of hip fractures between 2011 and 2020. Patients with a DM diagnosis who had ≥3 postoperative glucose measurements during the first week after surgery and had a minimum of one-year follow-up were included. The coefficient of variation (the ratio of the standard deviation to the mean) was utilized to assess the GV. The final study population included 605 patients who were divided into three groups according to the extent of their GV. Short- and mid-term outcomes, including mortality, reoperations, readmissions, and postoperative infection rates were compared between the groups. Results: There was a non-significant trend towards increased rates of mortality (p = 0.06), readmissions (p = 0.22) and postoperative infections (p = 0.09) in the high GV group. The rate of revisions at the latest follow-up was significantly higher in the high GV group when compared to the two other groups (p = 0.04). Conclusion: For diabetic patients undergoing hip fracture fixation, a higher GV in the postoperative period was associated with increased rates of all-cause revision surgery and may be associated with increased mortality, readmission rates, and surgical site infections. Glucose levels of diabetic patients should be meticulously monitored and controlled in the postoperative period in an effort to contain the sequelae associated with elevated GV and to identify patients in need of closer observation and follow-up.

Surgical Techniques Development doi: 10.3390/std13030017

Authors: Koichi Okamoto Jun Kinoshita Hiroto Saito Itasu Ninomiya Noriyuki Inaki Hiroyuki Takamura

We report a case in which a 74-year-old man suffering from esophageal achalasia complicated with epiphrenic esophageal diverticulum was successfully treated with a simultaneous laparoscopic surgery. The gentleman was referred with symptoms suggestive of a passage disorder in the lower esophagus for the past 5 years. Esophagogastroduodenoscopy demonstrated an epiphrenic diverticulum at the left wall of the lower esophagus, and esophagography led to the suspicion of a combined esophageal achalasia. A simultaneous laparoscopic surgery with an abdominal approach was performed in which, following the opening of the esophageal hiatus, the diverticular wall was separated from the mediastinal organs and diverticulectomy was performed with linear staplers. After Heller’s myotomy, Dor’s fundoplication was subsequently performed in which both the incisional line of muscle layer and the suturing line of diverticulectomy were wrapped by the fornix of the stomach to make up for the wall strength and avoid the suture leakage. It was theoretically considered logical and effective to reinforce this vulnerable site with Dor’s fundoplication. He had an uneventful recovery and a rapid relief from symptoms following surgery.