Donor Site Morbidity after Lumbar Artery Perforator Flap Breast Reconstruction.

BACKGROUND: The lumbar artery perforator flap is a second-choice flap in autologous breast reconstruction whenever a deep inferior epigastric artery perforator (DIEP) flap is not possible. Ideal candidates are pear-shaped women who do not have enough bulk on the abdomen or thighs. Patient-reported "satisfaction with breasts" is excellent but we were curious about the donor site morbidity. METHODS: We performed a retrospective study of all lumbar flap breast reconstructions performed between 2010 and 2019. Patients were invited by e-mail and telephone to take part in a BREAST-Q survey. RESULTS: One hundred fifty-four flaps were performed in 110 patients. Sixty-three patients filled out the BREAST-Q questionnaire. The most frequently observed donor site complications are seroma (35.1%), dehiscence (8.4%), and hematoma (3.2%). Correction of the donor site scar was performed in 31.8% of patients, lipofilling of the donor flank in 5.2%, and liposuction of the contralateral flank in 18.3% of patients. Body mass index (BMI) was the only significant risk factor for donor site complications. Patient-reported "satisfaction with donor site appearance" was good but significantly lower for primary reconstructions compared with secondary and tertiary procedures. Flap weight significantly influences patient-reported "physical wellbeing of the donor site." Ninety-seven percent of patients would recommend the surgery to someone in a similar position and would do it all over. CONCLUSION: The lumbar artery perforator flap is a good alternative for breast reconstruction in selected patients. The donor site issues consist mainly of seromas, prolonged discomfort, and a scar that might be noticeable to others, but patient-reported satisfaction is very high.

Incisional lumbar hernia after the use of a lumbar artery perforator flap for breast reconstruction.

Autologous breast reconstruction with a perforator flap has become increasingly popular. The free lumbar artery perforator (LAP) flap has been described as a good alternative for autologous breast reconstruction. The LAP flap is a perforator flap based on a single pedicle. This flap is easy to harvest, with minimal donor-site morbidity. We present a case of a lumbar incisional hernia after LAP flap breast reconstruction in a 53-year-old patient. The patient had been treated with a bilateral mastectomy for cancer. Secondary breast reconstruction was performed with a bilateral DIEP flap. Reoperation was necessary because of a failed DIEP flap at the left side. Reconstruction was performed with a free LAP flap. The patient was referred for a right lumbar incisional hernia at the donor-site of the LAP flap. Open repair was performed with a retroperitoneal mesh. The thoracolumbar fascia was closed in with a running suture. Lumbar artery perforator is a perforator flap based on a single pedicle. Although it does not sacrifice any muscle and seems to be associated with minimal donor-site morbidity, we present the first report of a lumbar incisional hernia repair after LAP flap breast reconstruction treated using an open retroperitoneal mesh repair.

Massive femur defect after Ewing's sarcoma resection reconstructed with a free vascularised fibular graft in a four-year-old girl.

Background: Ewing's sarcoma is the second most common primary malignant bone tumour in children. Depending on localisation and extent, massive bone defects remain when curative surgery is performed. Whereas in the past, limb amputation was often unavoidable to obtain curative resection, nowadays different limb saving reconstructive options are available.Case report: We report the successful reconstruction of a massive femur defect with a free vascularised fibular graft (FVFG) after Ewing's sarcoma resection in a four-year-old girl. Both the age of the patient and the extensive graft hypertrophy makes this case exceptional.Conclusion: Femur reconstruction with a FVFG is a rarely performed and complex procedure in young children. It is an excellent reconstructive technique for large long bone defects, which can avoid limb amputation without compromising oncologic outcome.

Takotsubo Cardiomyopathy Induced by Epinephrine Infiltration for Liposuction: Broken Heart Syndrome.

Broken heart syndrome, more commonly known as Takotsubo cardiomyopathy (TCM), is an acute cardiac condition. It is characterized by regional cardiac wall motion abnormalities triggered by physical or emotional stress or administration of catecholamines such as epinephrine. The initial clinical presentation is similar to an acute coronary syndrome and must be ruled out. Visualization of the characteristic wall motion will trigger the diagnosis of TCM. In this case report, we present a 50-year-old woman with additional liposuction and fat grafting after autologous breast reconstruction. Shortly after infiltration with a solution containing epinephrine to achieve vasoconstriction, hypotension and bradycardia was noticed. This escalated into full asystole for which cardiac resuscitation was required. ST-elevations and a decrease in systolic function were clear indicators for urgent coronarography and ventriculography. These confirmed the diagnosis of TCM. Infiltration with epinephrine-containing products to achieve local vasoconstriction is used routinely. Medical professionals should be aware that this can trigger a TCM with an estimated mortality rate of 5%. No evidence of a specific preventive measure currently exists. We know that women with a neurologic or psychiatric comorbidity and high levels of stress are more at risk. Reducing stress and anxiolytic medication prior to surgery could be useful. We also know that the cardiac wall motion abnormality is mainly related to ß-adrenoreceptors. The use of a selective α-adrenoreceptor agonist could be considered. Further research in the pathophysiology and incidence of TCM could improve identification of patients at risk and lead to more effective prevention and treatment.

Abdominoplasty and gluteoplasty after massive weight loss: an all-in-one technique.

INTRODUCTION: Patients requesting body-contouring surgery after massive weight loss often present with abdominal and lumbar skin excess as well as gluteal ptosis and loss of gluteal projection. In order to restore gluteal projection a circular abdominoplasty in combination with an autologous gluteal augmentation (all-in-one technique) can be performed. OBJECTIVE: To compare outcomes for patients who underwent a circular abdominoplasty with or without autologous gluteal augmentation. METHODS: In a retrospective study we analyse 24 patients who underwent a circular abdominoplasty between 2006 until 2014 at the University Hospital of Ghent, Belgium. Fourteen patients underwent a classic circular abdominoplasty (4 men and 10 women). Ten patients underwent the all-in-one technique (all women). Mean age was 43 in the classic abdominoplasty group and 41 in the all-in-one technique group. All the patients endured massive weight loss after bariatric surgery. Gluteal augmentation was performed using lumbar dermal fat rotation flaps based on perforators of the 4th lumbar artery. For statistical analysis a Fisher exact tests was used. RESULTS: Postoperative photographs showed that gluteal projection had been increased in patients who underwent the all-in-one technique. The mean operation time in this group was 3h49min versus 2h47min in the group who underwent a classic circular abdominoplasty. The mean hospital stay in both groups was 6 days. Complication rate was comparable between both the groups. CONCLUSION: The all-in-one technique is an efficient method to improve both abdominal and gluteal body contour in patients who endured massive weight loss.

Lumbar artery perforators: an anatomical study based on computed tomographic angiography imaging.

BACKGROUND: The free lumbar artery perforator flap has recently been introduced as a potentially valuable option for autologous breast reconstruction in a subset of patients. Up to date, few anatomical studies, exploring the lumbar region as a donor site for perforator- based flaps, have been conducted. METHODS: An anatomical study of the position of the dominant lumbar artery perforator was performed, using the preoperative computed tomographic angiography images of 24 autologous breast reconstruction patients. In total, 61 dominant perforators were determined, 28 on the left and 33 on the right side. A radiologist defined the position of the perforator as coordinates in an xy-grid. RESULTS: Dominant perforators were shown to originate from the lumbar arteries at the level of lumbar vertebrae three or four. Remarkably, approximately 85% of these lumbar artery perforators enter the skin at 7-10 cm lateral from the midline (mean left 8.6 cm, right 8.2 cm). CONCLUSION: This study concludes a rather constant position of the dominant perforator. Therefore, preoperative-computed tomographic angiography is not always essential to find this perforator and Doppler ultrasound could be considered as an alternative, thereby carefully assessing all advantages and disadvantages inherent to either of these imaging methods.

A simple concept for covering pressure sores: wound edge-based propeller perforator flap.

We present a new surgical modification to allow propeller perforator flaps to cover pressure sores at various locations. We used a propeller perforator flap concept based on the detection of newly formed perforator vessels located 1 cm from the wound margin and stimulated by the chronic inflammation process. Between January 2009 and January 2017, 33 wound edge-based propeller perforator flaps were used to cover pressure sores at various locations in 28 patients. In four cases more than one flap was used on the same patient. The patients comprised 18 males and 10 females with a mean age of 41·25 (range, 16-70) years. All patients underwent follow-up for 0-12 months. The mean follow-up duration was 5·03 months. Venous congestion was observed in three flaps that were rotated by 180° (9·1%). However, there was a significant difference between flaps rotated by 90° and 180° according to the complication rate (P = 0·034). Out of 33 flaps, 29 flaps healed uneventfully. Patients were able to sit and lie on their flaps three weeks after surgery. In our study, we were able to obtain satisfying final results using these novel flaps.

The Lumbar Artery Perforator Flap in Breast Reconstruction.

SUMMARY: The lumbar artery perforator flap is a valuable alternative in breast reconstruction whenever the deep inferior epigastric perforator flap is not feasible because of insufficient or unavailable abdominal tissue. The advantage is the ideal shape and consistency of the flap, in addition to the option to perform a nerve anastomosis with the cluneal nerve. The anatomy is consistent, but there are some technical issues related to the short perforator and difficult surgical exposure in the lower back region. The inclusion of a vascular interposition graft improved the authors' results and facilitated their technical challenges and final inset of the flap. These videos guide the surgeon through the different steps involved in a breast reconstruction with the lumbar artery perforator flap.

Reconstruction of the Achilles tendon and overlying soft tissue by free composite anterolateral thigh flap with vascularized fascia lata.

Segmental loss of the Achilles tendon with overlying soft tissue and skin defect remains a complex reconstructive challenge. Successful reconstruction combines tendon repair with coverage of the defect by soft tissue flaps, creating an entity that meets up to three predetermined goals: (1) approaching preinjury functionality, (2) resisting shearing forces, and (3) achieving an esthetic result. From June 2009 to June 2011, our center submitted six patients to a one-stage procedure correcting the Achilles tendon using a composite free anterolateral thigh (ALT) flap with vascularized fascia lata. The flap sizes ranged from 5 to 8 cm in width and 16 to 20 cm in length and all flaps included vascularized fascia lata which was rolled to serve as an Achilles tendon. After reconstruction our patients showed good functional results, these patients could walk, climb stairs, and tiptoe again without support. Moreover, normal footwear could be worn. A free composite ALT flap with vascularized fascia lata is a reliable option for coverage of Achilles tendon and overlying soft tissue defects, even in elderly patients.

A Novel Technique for Preventive Lymphovenous Anastomosis: Anastomosing a Ligated Lymphatic Vessel.

BACKGROUND: Lymphedema is defined as a chronic condition, caused by lymphostasis. A major part in the Western world consists of iatrogenic lymphedema caused by surgery to the lymph nodes of the axilla or groin. Prophylactic lymphovenous anastomosis (LVA) could be beneficial in the prevention of lymphedema of the extremities. These procedures require experienced supramicrosurgeons and can be time consuming, which might be the reasons why prophylactic LVA has not yet been widely implemented in the treatment of cancer. Due to the small diameter of lymphatic vessels, it remains challenging to identify the lumen, and therefore, anastomoses are prone to back wall stitching. Different inventive procedures have been described making use of stents or monofilament sutures. METHODS: In this article, we describe a newly developed and straightforward technique for LVA in 4 patients who underwent an axilla dissection and 1 patient who underwent a dissection of the groin lymph nodes. This latter approach makes use of clipping of the lymphatic vessel during lymph node dissection, and remains ligated during anastomosis. The candidate vein was the V. thoracodorsalis for the axilla and the V. circumflexa superficialis for the groin. We describe the feasibility, average duration, and complications. RESULTS: Performing an end-to-side anastomosis on a clipped lymphatic vessel minimizes the problem of back wall stitching as well as the trouble of finding the lumen due to collapsing of the vessel. The turgor of the lymphatic vessel is maintained and makes anastomosing easy. Average time for LVA was 33.4 minutes and 1 minor complication was seen. CONCLUSION: We believe that this approach might be of value in popularizing LVA in the treatment or prevention of different conditions such as breast cancer-related lymphedema.

Nipple reconstruction in autologous breast reconstruction after areola-sparing mastectomy.

INTRODUCTION: The number of patients requesting prophylactic mastectomy with immediate reconstruction is rising. The oncological safety of techniques preserving the nipple and/or areola complex is still controversial. Nevertheless, nipple-sparing mastectomy (NSM) and areola-sparing mastectomy (ASM) are becoming increasingly popular. After ASM, traditional nipple reconstruction techniques can be a disappointment and can lead to a deep groove around the new nipple. We describe a technique to overcome these issues and analyzed how three types of mastectomy (skin-sparing mastectomy or SSM, ASM, and NSM) compare to one another by looking into the number of wound infections, extra procedures for the loss of projection, nipple necrosis, and BREAST-Q scores. METHODS: We retrospectively analyzed 467 breast reconstructions performed in 351 patients between 2011 and 2017 at the University Hospital of Gent. Patients were asked to fill out the BREAST-Q questionnaire and patient-reported outcomes were analyzed and correlated to demographic information. RESULTS: Patients undergoing a nipple reconstruction after ASM are experiencing similar rates of wound problems, extra surgical procedures for the loss of projection and necrosis, compared to women with a history of SSM. When considering the "satisfaction with breast" and "satisfaction with outcome" modules of the BREAST-Q, we noted that nipple-sparing mastectomy (NSM) patients report lower scores than SSM and ASM patients and ASM patients seem to report a higher "satisfaction with nipple," than the other two treatment groups. CONCLUSION: An ASM is a valuable alternative to a nipple-sparing mastectomy and leads to a good esthetic result and patient satisfaction.

Outcome of arterial reconstruction and free-flap coverage in diabetic foot ulcers: long-term results.

BACKGROUND: Major amputation for advanced soft tissue loss with bone and tendon exposure, can be prevented in diabetes patients with a combined arterial reconstruction and free-flap transfer. We reviewed our 15-year outcome and evaluated the feasibility to save diabetic feet by means of this aggressive strategy. METHODS: A total of 55 type II diabetes patients (42-80 years of age), hospitalized between January 1992 and December 2006 for a combined arterial reconstruction and free-flap transfer, were followed until December 2007. All would have otherwise required at least a below-knee amputation. Arterial reconstructions, preferentially with autologous vein, were performed in combination with free tissue transfer, simultaneously or staged. The rectus abdominis muscle was the most frequently used muscle graft, although in recent years a growing number of alternative muscle and perforator flaps were used. RESULTS: The mean follow-up was 22 months (range: 1-180 months). Major complications occurred in 37% with only one in-hospital death. Major amputations were performed in 15 patients, 5 in the early postoperative period. The 1-year and 3-year limb salvage rates were 75.8 and 64.3%, with a 1-year and 3-year amputation-free survival of 69.5% and 55.8%. The 1-year and 3-year secondary patency for graft and free flap was 78.7% and 60.2%, respectively. Renal insufficiency was a major risk factor for limb loss (Hazard Ratio [HR] 5.581 (95% Confidence Interval [CI] 1.384-22.5)). Independent ambulation was regained in 38 patients. CONCLUSIONS: Combined arterial reconstruction and free tissue transfer provides an excellent long-term result with regard to amputation-free survival and limb salvage. It should be considered in every diabetes patient with extensive soft tissue deficits before amputation is performed.

Lumbar Flap versus the Gold Standard: Comparison to the DIEP Flap.

BACKGROUND: The lumbar artery perforator flap is an excellent free flap for breast reconstruction whenever the deep inferior epigastric perforator (DIEP) flap is not an option. The main indication is a lack of abdominal bulk, often seen in young BRCA-positive women seeking prophylactic amputation and immediate reconstruction. METHODS: Between October of 2010 and July of 2016, a total of 661 free flap breast reconstructions were performed. The authors retrospectively analyzed patient demographics, perioperative parameters, and secondary corrections. RESULTS: Seventy-six lumbar artery perforator flaps were retained and compared with a cohort of 560 DIEP flaps. The average body mass index for lumbar patients was 23.8 kg/m, with a mean age at operation of 46.3 years. Average body mass index for DIEP patients was 25.2 kg/m, with a mean age at operation of 48.8 years old. Lumbar artery perforator flap weight was 504 g (range, 77 to 1216 g) on average versus 530 g (range, 108 to 1968 g) for the DIEP flaps. The amount of corrective procedures performed was very similar in both cohorts: 13 percent of the lumbar artery perforator and 12 percent of the DIEP patients underwent no procedures, 62 percent in both groups underwent one procedure, and 25 percent versus 27 percent underwent two or more procedures. Lipofilling was performed in 48 percent of lumbar artery perforator flaps compared with 57 percent of the DIEP flaps (p = 0.14). Mean volume injected was 98.0 cc and 125.1 cc for lumbar artery perforator and DIEP flaps, respectively (p = 0.071). CONCLUSIONS: The lumbar flap is a good alternative whenever a DIEP flap is not possible. Bilateral autologous reconstruction is possible even in very thin patients, and secondary corrections are comparable to those for the DIEP.

Comparing the Lumbar and SGAP Flaps to the DIEP Flap Using the BREAST-Q.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is the gold standard in autologous breast reconstruction. When the abdomen is not available, alternative donor sites can be found at the buttock, the lumbar region, or the thighs. These flaps are referred to as second-choice flaps. This study compares the superior gluteal artery perforator (SGAP) flap and the lumbar artery perforator (LAP) flap to the DIEP flap using patient-reported outcomes. METHODS: A retrospective study was performed reviewing the records of 417 women who underwent a free flap breast reconstruction with either a DIEP, an LAP, or an SGAP flap, between 2006 and 2018. Patients were asked to fill out the BREAST-Q questionnaire, and patient-reported outcomes were analyzed and correlated to the demographic information. RESULTS: The response rate was 54.5 percent, with 50 LAP, 153 DIEP, and 25 SGAP flap patients participating. When questioned about their satisfaction with breasts and satisfaction with outcome, all three procedures were rated similarly high. When comparing the physical well-being of the donor site and appearance of the donor site, LAP flap patients reported significantly lower scores than DIEP and SGAP flap patients. CONCLUSIONS: Patients who undergo LAP or SGAP flap breast reconstruction seem similarly satisfied with the appearance and outcome of their free flap breast reconstruction compared with DIEP flap patients. The donor-site morbidity and its impact on the patient's well-being in SGAP and LAP flap patients have been underestimated. Despite more donor-site discomfort, the LAP and SGAP flaps are feasible alternatives whenever the DIEP flap is not possible.

The Prepectoral, Hybrid Breast Reconstruction: The Synergy of Lipofilling and Breast Implants.

Breast reconstruction modalities are based on autologous tissue transfer, implants, or a combination of both. The aim of an allogeneic breast reconstruction is to minimize the impact of the implant on surrounding tissues to achieve an aesthetically pleasing result. Accurate tissue coverage, proper implant selection, and implant location are the absolute concerns in planning an implant-based reconstruction. METHODS: A single surgeon's experience with the ergonomic, hybrid approach in primary and secondary breast reconstructions is presented. The hybrid approach is based on tissue expansion followed by serial sessions of fat grafting to augment the residual autologous (subcutaneous) compartment. The last step included the insertion of a prepectoral, ergonomic implant to obtain central core projection and additional volume. RESULTS: Fifty-six hybrid breast reconstructions were performed with a mean follow-up of 24.1 months. Aesthetic outcomes and patient satisfaction have been good with pleasing breast projection, natural breast motion, and optimal coverage of the prepectoral implants. CONCLUSIONS: The hybrid reconstructive approach is a reliable technique to improve the outcomes in implant-based breast reconstructions. The 2-step, prepectoral approach with expander-to-implant exchange allows better control of the final breast shape, and complications related to submuscular approaches are avoided. Fat grafting adds an autologous benefit to obtain natural results.

Bilateral DIEP Flap Breast Reconstruction to a Single Set of Internal Mammary Vessels: Technique, Safety, and Outcomes after 250 Flaps.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard in autologous breast reconstruction. In bilateral cases, both flaps are often anastomosed to the internal mammary vessels on either side of the sternum. The authors propose a method in which both flaps are anastomosed to only the right side internal mammary artery and vein. METHODS: Between November of 2009 and March of 2018, 125 patients underwent bilateral DIEP flap breast reconstruction with this technique. One flap is perfused by the anterograde proximal internal mammary artery and the second one by the retrograde distal internal mammary artery after presternal tunneling. Patient demographics and operative details were reviewed retrospectively. RESULTS: Two hundred fifty flaps were performed. One hundred fifty-two flaps were prophylactic or primary reconstructions (60.8 percent), 70 were secondary reconstructions (28 percent), and 28 were tertiary reconstructions (11.2 percent). Mean patient age was 46 years, and the mean body mass index was 25 kg/m. Sixty patients underwent radiation therapy or chemotherapy (48 percent). The authors encountered one significant partial failure (0.4 percent) and nine complete flap failures (3.6 percent). The authors did not see a statistically significant predisposition for failure comparing the retrograde with the anterograde flow flaps, nor when comparing the tunneled with the nontunneled flaps. CONCLUSIONS: The authors' results show that anastomosing both DIEP flaps to a single set of mammary vessels is safe and reliable. The authors conclude that the retrograde flow through the distal internal mammary artery is sufficient for free flap perfusion and that subcutaneous tunneling of a free flap pedicle does not predispose to flap failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Free flaps for lower limb soft tissue reconstruction in children: Systematic review.

BACKGROUND: Since the first reports on microsurgery in children, there has been an evolution in the reconstruction of soft tissue defects as evidenced by a shift to free flaps as the first-line treatment. METHODS: The primary objective of this systematic review was to compare the complication rate of free perforator/fasciocutaneous flaps with free muscular/myocutaneous flaps in pediatric lower limb soft tissue reconstructions. The secondary objective was to evaluate the frequency and severity of complications for both reconstructive options. A search was performed in the databases PubMed, Web of Science, Embase, Scopus, and Cochrane Library depending on predefined inclusion criteria. RESULTS: The evolution to perforator flaps from muscular and myocutaneous flaps is reflected in this systematic review as demonstrated by the anterolateral thigh (ALT) flap, which is the most common reconstructive option with a very low complication rate (11.3%) and flap loss. The latissimus dorsi (LD) flap was the second most frequently reported reconstruction with a complication rate comparable with that of the thoracodorsal artery perforator (TDAP) flap (32% vs. 39%, respectively), but the former suffers few failures. The radial forearm (RFA) fasciocutaneous flap can be considered a good alternative for ALT and TDAP flaps with a very low complication rate (16%) and no flap loss. CONCLUSIONS: The ALT flap is considered the best reconstructive method for pediatric lower limb soft tissue defects. More adequate prospective studies specifically concerning free flap reconstructions for lower limb defects in children are necessary in the future to provide guidelines for treatment and optimize outcomes in the long term.

Use of the thoracodorsal artery perforator (TDAP) flap with implant in breast reconstruction.

The latissimus dorsi (LD) musculocutaneous flap with implant has been widely used for breast reconstruction. This technique, which is safe and reliable, results in the sacrifice of the largest muscle in the body with high seroma incidence in the donor site. The thoracodorsal artery perforator (TDAP) flap spares the LD muscle. However, the TDAP has never been used together with implant for breast reconstruction. We present our strategies in sparing the LD muscle by using the TDAP flap with an implant beneath. The perforator was always mapped preoperatively. The TDAP flap was designed with the perforator located at the proximal part. Modifications to the flap should be done when multiple small perforators are found or when the perforator enters the subcutaneous tissue in the middle of the flap. A small segment of the muscle is included in the flap behind the perforator (LD-muscle sparing TDAP type I) to protect perforator compression by the implant. In very thin patients, a larger segment of the LD is needed to cover the implant (LD muscle-sparing TDAP type II). In both situations, the rest of the LD muscle is spared with its motor innervation. We present 4 patients who underwent a TDAP flap with implant for breast reconstruction. The flaps were transferred successfully. No seroma formation occurred. Combining a TDAP flap with an implant is feasible. Perforator mapping with correct flap design is the keystone in this technique. Reducing donor site morbidity and seroma rate are the ultimate goals of this technique. The TDAP flap should be modified to an LD muscle-sparing version in any case of unfavorable anatomic or clinical situations.

Indications and Controversies for Nonabdominally-Based Complete Autologous Tissue Breast Reconstruction.

Autologous breast reconstruction can be challenging in mastectomy patients who are not eligible for a deep inferior epigastric artery perforator flap reconstruction. Depending on body habitus, alternative donor sites for free flap transfer can be found on the back, the thighs, and in the gluteal area. These alternative flaps can demand a higher level of expertise, which should be mastered by the modern day reconstructive microsurgeon. The flap choice should be tailored individually to each patient and should not be limited by the difficulty of the surgery.