Literature Review: Robotic-Assisted Harvest of Deep Inferior Epigastric Flap for Breast Reconstruction.

INTRODUCTION: Robotic-assisted surgery is gaining popularity because of reported improvement in aesthetic outcomes while reducing the occurrence of complications compared with conventional surgical methods. Deep inferior epigastric perforator (DIEP) flap harvesting has a long track record as a viable procedure for autologous reconstruction of the breast. In this literature review, we describe the feasibility of using the robotic platform in DIEP flap harvest. METHODS: The Preferred Reporting Items for Systemic Reviews and Meta-Analysis methodology was to guide the literature review. PubMed and Scopus databases were searched from inception to June 6, 2022. The Medical Subject Heading terms and keywords used to conduct this search are as described: "Robotic AND deep inferior epigastric perforator AND Breast reconstruction." RESULTS: Seven publications, detailing a total of 56 robotic-assisted DIEP flap harvest procedures, were selected for review. Four publications used the transabdominal preperitoneal approach, whereas 2 exclusively used a totally extraperitoneal approach, and 1 compared the 2 approaches. The measured outcomes included technical feasibility of flap harvest in cadavers, viable flap harvest in live patients, harvest time and pedicle dissection time, pedicle length, fascial incision length, donor site pain, need for postoperative narcotic, donor site morbidity, and hernia formation. Overall, the reviewed articles demonstrated successful DIEP flap harvesting without the need for conversion to the conventional open procedure. Postoperative complications were minimal. Robotic DIEP flap harvest was shown to be safe and there were no reports of donor-site morbidity in the studies reviewed. The main advantages of the robotic approach include decreased postoperative pain and length of hospital stay, along with improved aesthetic outcomes. The main disadvantages are increased operative time and cost. CONCLUSIONS: Although at its current iteration, the robotic-assisted DIEP flap is feasible, it may not be practical in all settings. Furthermore, the true benefit of the robotic platform is yet to be determined, as more long-term studies are necessary.

How to minimize the pain of local anesthetic administration.

Expertise in the delivery of effective local analgesia is critical to the success of in-office procedures. Here's how to optimize patient outcomes and satisfaction.

Digital Pulley Reconstruction Using Pulley Allografts: A Comparison With Traditional Tendon-Based Techniques.

BACKGROUND: The safety and feasibility of sterile, acellular pulley allografts in reconstruction has been previously demonstrated. Comparisons with tendon-based techniques for pulley reconstruction have not been reported. We hypothesized that the use of allograft pulleys would result in reduced procedural time and equivalent clinical outcomes as compared with traditional tendon-based reconstructive techniques. METHODS: All cases of pulley reconstruction using either allograft pulleys or tendon-based pulley reconstruction between November 2013 and November 2015 were reviewed. Patients who underwent concomitant procedures were excluded. Patient demographics, comorbidities, operative details (tourniquet and total operative times, number of pulleys repaired), postoperative complications (surgical site infection, reoperation, stiffness, and persistent pain), disability of the arm, shoulder and hand scores, and follow-up data were recorded. A P value of <0.05 was considered significant. RESULTS: Fifteen pulleys in 10 patients were reconstructed: 5 tendon-based and 5 with allograft. Average length of follow-up was 12.5 ± 2.9 months. There was no difference in patient demographic factors or comorbidities between groups. The most common indication for surgery was trauma. Four of 5 patients in the allograft group had multiple pulleys reconstructed versus 1 in the tendon-based group. One patient in the tendon-based group required reoperation versus 0 in the allograft group. Total operative and tourniquet times were significantly reduced in the allograft group (46 ± 5.5 vs 89 ± 12.9 minutes and 34 ± 6.8 vs 63 ± 5.3 minutes; P = 0.015 and 0.014). Postoperative disability of the arm, shoulder and hand scores were lower in the allograft group (56.8 vs 3.6, P = 0.11). There was no significant difference in postoperative range of motion between groups. CONCLUSION: Pulley reconstruction with allograft is an efficient, technically feasible, reconstructive technique that adheres to the principle of replacing like with like, while eliminating donor site morbidity. Overall operative and tourniquet times were significantly shorter using allograft pulleys for pulley reconstruction.

Total phenolic compounds in milk from different species. Design of an extraction technique for quantification using the Folin-Ciocalteu method.

Milk protects the health of newborns because it contains essential compounds that perform metabolic activities. Despite these benefits, the study of phenolic compounds in milk has been poorly explored. The objective of this study was to develop and validate a technique for extracting total phenolic compounds (TPCs) from a milk matrix and then analyzing them using the Folin-Ciocalteu method. The extraction technique was applied to goat milk and involved the addition of methanol, acetonitrile, and Carrez I and II reagents, after which protein was separated from fat through centrifugation. Subsequently, the technique was applied to goat (69.03±6.23mg GAE/L), cow (49.00±10.77mg GAE/L), sheep (167.6±58.77mg GAE/L) and human milk (82.45±12.3mg GAE/L). The technique showed an acceptable linearity (R(2)=0.9998), limit of detection (6.03mg GAE/L) and quantification (16.2mg GAE/L), repeatability (RSD=4%), reproducibility (RSD=6.8%) and recovery (>85.41%); it is thus effective and can be used in the routine analysis of milk. TPCs obtained from each type of milk indicate a high variability among species and among members of the same species.

Outcomes of abdominal wall reconstruction with acellular dermal matrix are not affected by wound contamination.

BACKGROUND: The optimal type of mesh for complex abdominal wall reconstruction has not been elucidated. We hypothesized that AWRs using acellular dermal matrix (ADM) experience low rates of surgical site occurrence (SSO) and surgical site infection, despite increasing degrees of wound contamination. STUDY DESIGN: We retrospectively reviewed prospectively collected data from consecutive abdominal wall reconstructions with ADM over a 9-year period. Outcomes of abdominal wall reconstructions were compared between patients with different CDC wound classifications. Univariate and multivariate logistic regression and Cox proportional hazard regression analyses identified potential associations and predictive/protective factors. RESULTS: The 359 patients had a mean follow-up of 28.3 ± 19.0 months. Reconstruction of clean wounds (n = 171) required fewer reoperations than that of combined contaminated (n = 188) wounds (2.3% vs 11.2%; p = 0.001) and trended toward experiencing fewer SSOs (19.9% vs 28.7%, p = 0.052). There were no significant differences between clean and combined contaminated cases in 30-day SSI (8.8% vs 8.0%), hernia recurrence (9.9% vs 10.1%), and mesh removal (1.2% vs 1.1%) rates. Independent predictors of SSO included body mass index ≥30 kg/m(2) (odds ratio [OR] 3.6; p < 0.001), 1 or more comorbidities (OR 2.5; p = 0.008), and defect width ≥15 cm (OR 1.8; p = 0.02). CONCLUSIONS: Complex abdominal wall reconstructions using ADM demonstrated similar rates of complications between the different CDC wound classifications. This is in contradistinction to published outcomes for abdominal wall reconstruction using synthetic mesh that show progressively higher complication rates with increasing degrees of contamination. These data support the use of ADM rather than synthetic mesh for complex abdominal wall reconstruction in the setting of wound contamination.

Vaculitis sistemica y riñon, poliarteritis nodosa clasica (PAN) y poliangeitis microscopica (PAM) / Systemic vasculitis and kidney, classical polyarteritis nodosa and microscopic polyangeitis

Las vasculitis sistémicas constituyen un grupo de enfermedades que se caracterizan por la inflamación aguda multifocal y la necrosis fibrinoide de la pared de los vasos sanguíneos que pueden tener diferentes formas de expresión, desde la forma local autolimitada hasta la forma difusa grave. Su incidencia se calcula en más de 25 casos por millón de habitantes y su evolución espontánea es fatal. Los tratamientos actuales con corticoides e inmunosupresores consiguen el control de la enfermedad en el 90 por ciento de los casos pero a expensas de una alta morbilidad. El índice de recaídas una vez lograda la remisión es del 40 por ciento dentro de los dos primeros años sin tratamiento y el hecho de sufrir una recaída constituye un índice de mal pronóstico. El caso número uno se trata de un paciente de 52 años, con antecedente de hipertensión arterial crónica, con una vasculitis clasificada como de vaso mediano (poliarterítis nodosa clásica) y falla renal aguda. El caso número dos corresponde a un hombre de 49 años con una vasculitis de pequeños vasos (poliangeítis microscópica) asociada a anticuerpos anticitoplasma del neutrófilo y afectación renal aguda severa.