Anatomical Study of Abdominal Wall Muscle Innervation to Optimize Retroperitoneal Vascular Approach.

INTRODUCTION: Different surgical approaches are used in aortic surgery. Retroperitoneal approaches can result in abdominal wall weakness and flank bulging. These approaches often require dissection of the anterolateral or anteromedial muscles of the abdominal wall. During dissection, the underlying nerves are at great risk of injury, which induces significant complications in abdominal wall muscles. Few studies have been conducted to minimize the risk of injury to these nerves. OBJECTIVES: This study aims to describe the trajectory of abdominal muscle motor nerves and their relationship to ribs and other anatomical landmarks. The secondary objective is to optimize surgical approaches by preserving the nerves. METHOD: We conducted 12 dissections on fresh cadavers. Nerve trajectories, communication between the intercostal nerves (9th-10th-11th) and the subcostal nerve (12th), and the distance from the nerve to the estimated projection point of intersection with the abdominal midline, umbilicus, and iliac crest was recorded. RESULTS: Our dissections identified the 12th subcostal nerve as the largest nerve. The 11th intercostal nerve exhibits more accessory branches than other nerves. Multiple communications and branches were observed between the 10th and 11th intercostal nerves and between the 11th and 12th nerves in the region from the anterior axillary line to the mid-clavicular line. The estimated projection point of intersection with the midline was 7.92 ± 1.24 cm supraumbilical for the 9th intercostal nerve, 3.92 ± 1.18 cm supraumbilical for the 10th, 1.08 ± 1.52 cm at the umbilical level for the 11th, and -3.33 ± 0.83 cm infraumbilical for the subcostal nerve. The distance between the iliac crest and the iliohypogastric nerve in the lateral jackknife position was 2.54 ± 0.65 cm. The 11th nerve had an angle in relation to the rib of between -45° and -10° (average: -24.6°), and the 12th nerve had a similar angle of between -30° and 0° (average: -18.3°). For the 11th nerve, the distance was between 0 and 5.5 cm (average: 2.92 cm); for the 12th nerve, it was between 0 and 3.0 cm (average: 1.71 cm). CONCLUSION: To preserve the 11th nerve, the optimal approach is a straight incision starting from the upper edge of the 11th rib towards the midline, 4 cm above the umbilicus; for the 12th nerve, the optimal approach is a straight incision starting from the upper edge of the 12th rib towards the midline, 1 cm below the umbilicus; for the iliohypogastric nerve, the optimal approach is an incision close to the iliac crest at a distance <1.5 cm. The estimated projection point of intersection between the nerve directions towards the midline can indicate the anatomical trajectory of nerves. A nerve projection towards the midline can provide valuable information about the anatomical location of a nerve. This study has utility in optimizing surgical approaches. A clinical study can confirm these anatomical results.

A new portable negative pressure wound therapy device: a prospective study investigating clinical outcomes.

OBJECTIVE: Closed surgical incision sites at high risk of complications, and with exudate or leakage, are increasingly being managed with closed incision negative pressure wound therapy (ciNPWT) to reduce tissue stress and increase the force necessary to disrupt the incision. This study was undertaken to investigate the performance and safety of a canister-based, single-use NPWT (suNPWT) system when used on closed surgical incision sites. METHOD: The investigation was designed as a prospective, open, non-comparative, multicentre study aimed at confirming the safety and performance attributes of the suNPWT system when applied to low-to-moderately exuding closed surgical incisions. The primary performance measure was the wound remaining closed from baseline to the last follow-up visit on day 14. Secondary performance measures included: wound and periwound condition; wear time of the system; product consumption; adherence to therapy; and patients' pain progress. Details of adverse events were also collected. RESULTS: Some 35 patients were recruited. The closed surgical incisions responded well to treatment with the tested suNPWT system. All wounds remained closed throughout the investigation. Consistent with other studies of ciNPWT reporting low infection rates, the current study observed either no or low exudation in 90.4% of wounds at the final visit, together with absence of surgical site infection. Pain severity levels were low, both at dressing change and during delivery of negative pressure. No serious adverse device events were reported. CONCLUSION: In this study, the suNPWT system supported the healing of closed surgical incisions with no safety concerns relating to its use.

Do different incision techniques for implant surgery affect gingival papilla height around dental implants? A retrospective study of 115 cases.

BACKGROUND: Surgical incision designs are considered closely correlated to gingival papilla of dental implants. This study aims to explore whether different incision techniques for implant placement and second stage surgery affect gingival papilla height. METHODS: Cases using different incision techniques (intrasulcular incisions or papilla sparing incisions) between November 2017 and December 2020 were selected and analyzed. A digital camera was used to capture images of gingival papilla at different time points. Ratio of papilla height to crown length using different incision techniques were measured and statistically compared. RESULTS: A total of 115 papillae (68 patients) were eligible according to the inclusion/exclusion criteria. The average age was 39.6 years. Decreased postoperative papilla height were observed after implant placement surgery in all groups without statistical difference. However, for second stage surgery, intrasulcular incisions lead to more atrophy in gingival papilla compared to papilla sparing incisions. CONCLUSIONS: Selection of incision techniques in implant placement surgery does not significantly affect papilla height. For second stage surgery, intrasulcular incisions significantly leads to more papilla atrophy compared with papilla sparing incisions. Trial registration KQCL2017003.

The distance between new and previous incisions does not affect skin necrosis in total knee arthroplasty: a parallel-randomized controlled clinical trial.

BACKGROUND: To avoid skin necrosis, an 8 cm distance between the new and previous incision is recommended in patients undergoing total knee arthroplasty (TKA). It was hypothesized that making a new incision less than 8 cm of the prior scar does not increase the risk of skin complications, and the new incision can be made anywhere, regardless of the distance from the previous scar. This study investigated how making a new incision, irrespective of the previous scars, affects skin necrosis. METHODS: In this parallel, randomized clinical trial, by simple randomization method using a random number table, 50 patients with single longitudinal knee scars were randomly assigned to two groups with a 1:1 ratio and 25 participants in each group. Patients with a minimum age of 60 and a single longitudinal previous scar on the knee were included. The exclusion criteria were diabetes mellitus, hypertension, morbid obesity, smoking, vascular disorders, cardiopulmonary disorders, immune deficiencies, dementia, and taking steroids and angiogenesis inhibitors. TKA was performed through an anterior midline incision, regardless of the location of the previous scar in the intervention group. TKA was performed with a new incision at least 8 cm distant from the old incision in the control group. Skin necrosis and scar-related complications were evaluated on the first and second days and first, second, and fourth weeks after the surgery. Knee function was assessed using the Knee Society Score (KSS) six months after the surgery. RESULTS: The baseline characteristics of the groups did not differ significantly. The average distance from the previous scar was 4.1 ± 3.2 cm in the intervention group and 10.2 ± 2.1 cm in the control group. Only one patient in the control group developed skin necrosis (P-value = 0.31). Other wound-related complications were not observed in both groups. The mean KSS was 83.2 ± 10.2 and 82.9 ± 11.1 in the intervention and control groups, respectively (P-value = 0.33). CONCLUSIONS: It is possible that in TKA patients, the new incision near a previous scar does not increase the risk of skin necrosis and other complications.

The influence zone: a critical performance measure for negative pressure wound therapy systems.

This article provides an introduction to the theory of, what is termed, the 'influence zone' in the context of negative pressure wound therapy (NPWT). It is a quantitative bioengineering performance measure for NPWT systems, to indicate their effectiveness, namely, how far from the wound bed edges a specific system is able to deliver effective mechano-stimulation into the periwound, and at which intensity. The influence zone therefore provides objective and standardised metrics of one of the fundamental modes of action of NPWT systems: the ability to effectively and optimally deform both the wound and periwound macroscopically and microscopically. Most important is the mechanical deformation of the periwound area to activate cells responsible for tissue repair, particularly (myo)fibroblasts. Notably, the influence zone must extend sufficiently into the periwound to stimulate (myo)fibroblasts in order that they migrate and progress the wound healing process, facilitating the formation of scar tissue, without overstretching the periwound tissues so as not cause or escalate further cell and tissue damage. The inclusion of the influence zone theory within research to investigate the efficacy of NPWT systems facilitates systematic comparisons of commercially available and potentially new systems. This approach has the capacity to guide not only research and development work, but also clinical decision-making. Recently published research found that inducing an effective influence zone first and foremost requires continuous delivery of the intended pressure to the wound bed.

Clinical and functional outcomes of cad/cam mandibular reconstruction with free fibular flap comparing traditional versus micro-invasive intraoral surgical approaches.

The surgical incision plays a pivotal role in any surgical procedure. A good surgical approach should allow optimal visualization, respect the anatomy and ensure the best aesthetic outcome possible, especially when the lesions involve the face. In this retrospective study, carried out from June 2014 to April 2018, different types of surgical approaches to perform mandibular reconstruction were compared. Twentyone patients who underwent mandibular reconstruction with free fibular flap (FFFs) using CAD-CAM technology and Virtual Surgical Planning (VSP) were included in the study, regardless the condition, the timing of reconstruction (primary vs secondary), the number of fibular segments or the type and size of the mandibular defect. The patients were treated for mandibular defects secondary to benign or low-grade oncological lesions and different non-oncological conditions. However, patients requiring neck dissection were excluded from the study. Patients were divided into two groups according to the type of surgical approach used: 7 patients received a traditional transcervical approach together with an intraoral approach, while 14 patients were operated through an intraoral approach combined with different microinvasive approaches, including the sub-mandibular, the retro-mandibular and the preauricular approaches. Different factors were statistically compared: characteristics of the harvested fibula, surgical timing, days of hospitalization, as well as complication, functional and aesthetic outcomes. According to this study, no statistically significant differences were observed between the two groups in any of the features considered. These results support the hypothesis that the combination of different microinvasive approaches and the traditional approach are superimposable, and they can be safely exchanged when the underlying defects allow it.

[Minimally invasive techniques for traumatic injuries of the cervical spine]. / Minimal-invasive Techniken bei traumatischen Halswirbelsäulenverletzungen.

Nowadays, although minimally invasive procedures are the standard for the treatment of thoracolumbar spinal injuries, these techniques are not yet established for the cervical spine. This is due to anatomical and technical reasons and also due to the fact that the classical anterior decompression and fusion procedure already fulfils the criteria of minimally invasiveness and is suitable for the vast majority of injuries. The existing literature consists mainly of case reports and small comparative cohort studies, the results of which are presented. There is a minimally invasive variant for nearly all open procedures, mainly in the upper cervical spine but also in the lower cervical spine. The further development of these promising techniques is still pending.

Comparison of the effectiveness of oblique and transverse incisions in the treatment of fractures of the middle and outer third of the clavicle.

BACKGROUND: Iatrogenic supraclavicular nerve injury is frequent during surgical repair of clavicle fractures through a transverse incision. The use of an oblique incision may be a potential approach to avoiding this complication. This study compared the clinical effectiveness of oblique and transverse incisions in the treatment of fractures in the middle and outer thirds of the clavicle. METHODS: This prospective observational study included patients with fracture of the mid-to-outer third of the clavicle between August 2011 and August 2016. We allocated the patients into 2 groups based on their choice of treatment: oblique incision (n = 62) and transverse incision (n = 64). We compared the following parameters between the 2 groups: operative time, intraoperative blood loss, postoperative fracture healing time, incision size, clinical complications, postoperative subjective satisfaction, and shoulder function. RESULTS: Operative time, postoperative fracture healing time, postoperative shoulder function (Constant-Murley and disabilities of the arm, shoulder and hand [DASH] scores), and clinical complications did not differ significantly between groups (all P > .05). The oblique incision group had less intraoperative blood loss (41.4 ± 16.4 vs. 65.3 ± 10.4 mL, P < .001) and smaller surgical incisions (3.6 ± 1.6 vs. 10.3 ± 2.6 cm, P < .001). The oblique incision group showed better outcomes for postoperative satisfaction (85.5% vs. 64.1%, P = .015), absence of shoulder numbness at the last follow-up (89.3% vs. 70.3%, P = .010), and satisfaction with the scar (90.3% vs. 3.1%, P < .001). CONCLUSION: Oblique incisions have several advantages over transverse incisions: less bleeding, smaller incisions, less iatrogenic injury to supraclavicular nerves, and higher patient satisfaction. These 2 approaches have equivalent effects on recovery of shoulder joint function.

Surgical incision induces learning impairment in mice partially through inhibition of the brain-derived neurotrophic factor signaling pathway in the hippocampus and amygdala.

Surgical incision-induced nociception contributes to the occurrence of postoperative cognitive dysfunction. However, the exact mechanisms involved remain unclear. Brain-derived neurotrophic factor (BDNF) has been demonstrated to improve fear learning ability. In addition, BDNF expression is influenced by the peripheral nociceptive stimulation. Therefore, we hypothesized that surgical incision-induced nociception may cause learning impairment by inhibiting the BDNF/tropomyosin-related kinase B (TrkB) signaling pathway. The fear conditioning test, enzyme-linked immunosorbent assay, and Western blot analyses were used to confirm our hypothesis and determine the effect of a plantar incision on the fear learning and the BDNF/TrkB signaling pathway in the hippocampus and amygdala. The freezing times in the context test and the tone test were decreased after the plantar incision. A eutectic mixture of local anesthetics attenuated plantar incision-induced postoperative pain and fear learning impairment. ANA-12, a selective TrkB antagonist, abolished the improvement in fear learning and the activation of the BDNF signaling pathway induced by eutectic mixture of local anesthetics. Based on these results, surgical incision-induced postoperative pain, which was attenuated by postoperative analgesia, caused learning impairment in mice partially by inhibiting the BDNF signaling pathway. These findings provide insights into the mechanism underlying surgical incision-induced postoperative cognitive function impairment.

Opioid analgesia and the somatosensory memory of neonatal surgical injury in the adult rat.

BACKGROUND: Nociceptive input during early development can produce somatosensory memory that influences future pain response. Hind-paw incision during the 1st postnatal week in the rat enhances re-incision hyperalgesia in adulthood. We now evaluate its modulation by neonatal analgesia. METHODS: Neonatal rats [Postnatal Day 3 (P3)] received saline, intrathecal morphine 0.1 mg kg-1 (IT), subcutaneous morphine 1 mg kg-1 (SC), or sciatic levobupivacaine block (LA) before and after plantar hind-paw incision (three×2 hourly injections). Six weeks later, behavioural thresholds and electromyography (EMG) measures of re-incision hyperalgesia were compared with an age-matched adult-only incision (IN) group. Morphine effects on spontaneous (conditioned place preference) and evoked (EMG sensitivity) pain after adult incision were compared with prior neonatal incision and saline or morphine groups. The acute neonatal effects of incision and analgesia on behavioural hyperalgesia at P3 were also evaluated. RESULTS: Adult re-incision hyperalgesia was not prevented by neonatal peri-incision morphine (saline, IT, and SC groups > IN; P<0.05-0.01). Neonatal sciatic block, but not morphine, prevented the enhanced re-incision reflex sensitivity in adulthood (LA < saline and morphine groups, P<0.01; LA vs IN, not significant). Morphine efficacy in adulthood was altered after morphine alone in the neonatal period, but not when administered with neonatal incision. Morphine prevented the acute incision-induced hyperalgesia in neonatal rats, but only sciatic block had a preventive analgesic effect at 24 h. CONCLUSIONS: Long-term effects after neonatal injury highlight the need for preventive strategies. Despite effective analgesia at the time of neonatal incision, morphine as a sole analgesic did not alter the somatosensory memory of early-life surgical injury.

[Surgical repair of the tunica albuginea for penis fracture: Selection of incision].

OBJECTIVE: To investigate the diagnosis and management of penile fracture. METHODS: From June 1993 to May 2017, 46 cases of penile fracture were treated in our hospital, averaging 33.5 (25－42) years of age and 3.45 (1－10) hours in duration, of which 41 occurred during sexual intercourse, 4 during masturbation and 1 during prone sleeping, 4 with hematuria, but none with dysuria or urethral bleeding. Hematoma was confined to the penis. Emergency surgical repair was performed for all the patients, 45 under spinal anesthesia and 1 under local anesthesia, 16 by coronal proximal circular incision and the other 30 by local longitudinal incision according to the rupture location on ultrasonogram. The tunica albuginea ruptures averaged 1.31 (0.5－2.5) cm in length, which were sutured in the "8" pattern for 6 cases and with the 3－0 absorbable thread for 18 cases. The skin graft or negative pressure drainage tube was routinely placed, catheters indwelt, and gauze used for early pressure dressing. In the recent few years, elastic bandages were employed for 3－5 days of pressure dressing and antibiotics administered to prevent infection. The stitches and catheter were removed at 7 days after surgery. RESULTS: Short-term postoperative foreskin edema occurred in 14 of the 16 cases of circular degloving incision, but no postoperative complications were observed in any of the cases of local incision. Twenty-eight of the patients completed a long-term follow-up of 49.4 (10－125) months, which revealed good erectile function, painless erection, and satisfactory sexual intercourse. CONCLUSIONS: For most penile fractures, local longitudinal incision is sufficient for successful repair of the tunica albuginea, with mild injury, no influence on the blood supply or lymph reflux, and a low rate complications. It therefore is obviously advantageous over circular degloving incision except when the cavernous body of urethra is to be explored, which necessitates circular degloving incision below the coronal groove.

Cutting electrocautery versus scalpel for surgical incisions: a systematic review and meta-analysis.

BACKGROUND: Although cutting electrocautery can be superior to the scalpel in reducing blood loss and incisional time, several reports associated electrocautery with higher rates of wound infection, impaired healing, and worse cosmesis. We performed this systematic review and meta-analysis to compare cutting electrocautery versus scalpel for surgical incisions. MATERIALS AND METHODS: We conducted a computerized literature search of five electronic databases and included all published original studies comparing cutting electrocautery and scalpel surgical incisions. Relevant data were extracted from eligible studies and pooled as odds ratios (ORs) or standardized mean difference (SMD) values in a meta-analysis model, using RevMan and Comprehensive Meta-analysis software. RESULTS: Forty-one studies (36 randomized trials, four observational, and one quasirandom study) were included in the pooled analysis (6422 participants). Compared with the scalpel incision, cutting electrocautery resulted in significantly less blood loss (SMD = -1.16, 95% CI [-1.60 to -0.72]), shorter incisional (SMD = -0.63, 95% CI [-0.96 to -0.29]) and operative times (SMD = -0.59, 95% CI [-1.12 to -0.05]), and lower pain scores (SMD = -0.91, 95% CI [-1.27 to -0.55]) with no significant differences in terms of wound infection rates (OR = 0.92, 95% CI [0.74-1.15]) or overall subjective scar score (SMD = -0.49, 95% CI [-1.72 to 0.75]). CONCLUSIONS: Surgical incision using electrocautery can be quicker with less blood loss and postoperative pain scores than the scalpel incision. No statistically significant difference was found between both techniques in terms of postoperative wound complications, hospital stay duration, and wound cosmetic characteristics. Therefore, we recommend routine use of cutting electrocautery for surgical incisions.

Numbness Around the Total Knee Arthroplasty Surgical Scar: Prevalence and Effect on Functional Outcome.

BACKGROUND: Numbness around the surgical scar can be a source of discomfort or dissatisfaction in a proportion of patients undergoing total knee arthroplasty (TKA). Literature reports wide variation in its prevalence and the consequence of numbness on the outcome of TKA is not clear. We investigated the prevalence of numbness, along with contributing factors, and assessed its effect on the functional outcome of TKA. METHODS: In total, 258 knees were included in this prospective patient-reported outcome measure case-control study. Demographic details, type and length of incision, pre-operative and 1-year post-operative Knee Society Scores were recorded and compared. RESULTS: The prevalence of numbness at 1 year was 53%, with a female preponderance. Patients older than 70 years were less affected. Discomfort due to numbness was recorded in 8.7% of the patients, 75% of which were female. The length of the incision correlated positively with the presence of numbness. The Knee Society Scores did not correlate with the presence or area of numbness. CONCLUSION: Our findings indicate a high prevalence of numbness after TKA. Nevertheless, numbness does not affect the functional outcome.

Contralateral cerebral hemoglobin oxygen saturation changes in patients undergoing thoracotomy with general anesthesia with or without paravertebral block: a randomized controlled trial.

PURPOSE: Perioperative analgesia during thoracotomy is often achieved by combining paravertebral block (PVB) with general anesthesia (GA). Functional near-infrared spectroscopy (NIRS) can detect changes in cerebral oxygenation resulting from nociceptive stimuli in the awake state or under sedation. We used NIRS to measure changes in cerebral blood flow provoked by thoracotomy incision made under GA and determine how these changes were influenced by supplementation of GA with PVB. METHODS: Thirty-four patients undergoing elective thoracotomy were enrolled. Patients were randomly assigned to a group receiving only GA, or GA combined with PVB (GA + PVB). Changes in cerebral oxygenated hemoglobin (ΔO2Hb), deoxygenated-Hb (ΔHHb), and total-Hb (ΔtotalHb) were evaluated by NIRS as surgery began. RESULTS: In the GA group, ΔO2Hb was significantly higher in the hemisphere contralateral to the side of surgery when the incision was made and 2 min after incision compared with the ipsilateral side (start of surgery, P < 0.01; 2 min, P < 0.05). In contrast, there were no significant changes in the ΔO2Hb at any of the time points in the GA + PVB group. Comparable with ΔO2Hb, the concentration of ΔtotalHb was significantly higher in the contralateral hemisphere in the GA group at the start of surgery (P < 0.05). CONCLUSIONS: Changes in the cerebral O2Hb concentration were detected by NIRS immediately after surgical incision under GA, but not in the presence of a PNB. NIRS could be used to monitor surgical pain. PVB inhibited changes in oxygenation induced by incision-provoked pain.

Closed incision negative pressure therapy: international multidisciplinary consensus recommendations.

Surgical site occurrences (SSOs) affect up to or over 25% of patients undergoing operative procedures, with the subset of surgical site infections (SSIs) being the most common. Commercially available closed incision negative pressure therapy (ciNPT) may offer surgeons an additional option to manage clean, closed surgical incisions. We conducted an extensive literature search for studies describing ciNPT use and assembled a diverse panel of experts to create consensus recommendations for when using ciNPT may be appropriate. A literature search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using key words 'prevention', 'negative pressure wound therapy (NPWT)', 'active incisional management', 'incisional vacuum therapy', 'incisional NPWT', 'incisional wound VAC', 'closed incisional NPWT', 'wound infection', and 'SSIs' identified peer-reviewed studies published from 2000 to 2015. During a multidisciplinary consensus meeting, the 12 experts reviewed the literature, presented their own ciNPT experiences, identified risk factors for SSOs and developed comprehensive consensus recommendations. A total of 100 publications satisfied the search requirements for ciNPT use. A majority presented data supporting ciNPT use. Numerous publications reported SSI risk factors, with the most common including obesity (body mass index ≥30 kg/m2 ); diabetes mellitus; tobacco use; or prolonged surgical time. We recommend that the surgeon assess the individual patient's risk factors and surgical risks. Surgeons should consider using ciNPT for patients at high risk for developing SSOs or who are undergoing a high-risk procedure or a procedure that would have highly morbid consequences if an SSI occurred.

The impact of surgical site occurrences and the role of closed incision negative pressure therapy.

Surgical site occurrences are observed in up to 60% of inpatient surgical procedures in industrialised countries. The most relevant postoperative complication is surgical site infection (SSI) because of its impact on patient outcomes and enormous treatment costs. Literature reviews ('SSI', 'deep sternal wound infections' (DSWI), 'closed incision negative pressure wound therapy' (ciNPT) were performed by electronically searching MEDLINE (PubMed) and subsequently using a 'snowball' method of continued searches of the references in the identified publications. Search criteria included publications in all languages, various study types and publication in a peer-reviewed journal. The SSI literature search identified 1325, the DSWI search 590 and the ciNPT search 103 publications that fulfilled the search criteria. Patient-related SSI risk factors (diabetes mellitus, obesity, smoking, hypertension, female gender) and operation-related SSI risk factors (re-exploration, emergency operations, prolonged ventilation, prolonged operation duration) exist. We found that patient- and operation-related SSI risk factors were often different for each speciality and/or operative procedure. Based on the evidence, we found that high-risk incisions (sternotomy and incisions in extremities after high-energy open trauma) are principally recommended for ciNPT use. In 'lower'-risk incisions, the addition of patient-related or operation-related risk factors justifies the application of ciNPT.

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature.

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical-related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena™ (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high-risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re-operation and re-hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero-haematoma formation and on the re-operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.

Prologue: transformational healing solutions.

In recent years, the provision of wound care for patients has dramatically improved through the development of new therapeutic options, allowing for a wide range of wound care therapy choices. In June 2014, an educational International Surgical Wound Forum (ISWF) was held to present current options in wound care to a multidisciplinary group of healthcare providers. Topics included negative pressure wound therapy with instillation and dwell time (NPWTi-d), surgical incision management (SIM), use of NPWT in the management of the open abdomen, epidermal skin harvesting, and advanced wound dressings. This supplement provides in-depth discussion of some of the topics covered at the 2014 ISWF.

Incisional negative pressure wound therapy for high-risk wounds.

With an ageing population and a growing number of people with obesity and/or undergoing advanced cancer therapies, there is an increasing risk of surgical site complications including surgical site infections (SSIs). Postoperative shifting of large mobilised tissue flaps, such as in abdominoplasties, remains a dreaded complication, particularly following massive weight loss. Besides negative implications for the patient, surgical site complications result in an economic burden due to prolonged and repeated wound treatments. Preventative tools to reduce SSIs are needed. In selected patients at high risk of SSI and/or wound breakdown, use of incisional NPWT has been shown to actively manage clean, closed surgical incisions. This article contains a review of scientific and clinical research relevant to incisional NPWT use over surgical incisions, with particular emphasis on the common problem of wound breakdown and SSI following body-contouring surgery in post-bariatric patients. Although there are a growing number of studies describing use of incisional NPWT in a variety of applications, including vascular, cardiac and orthopaedic, a literature search revealed few studies regarding incisional NPWT use post body-contouring surgery. In a clinical study of seroma formation, less seroma and haematoma formation was reported in post-bariatric patients who received incisional NPWT, versus the control, following body-contouring surgery. In another study of widely applied external NPWT wound dressings over the ventral and lateral trunk following post-bariatric abdominal dermolipectomy, results showed a significant reduction in exudate formation, earlier drain removal, and decreased length of hospitalisation, compared with conventional treatment. Additional controlled studies are needed to validate the clinical impact of incisional NPWT following body-contouring surgery, and to determine proper recommendations for its use.

Branching patterns of the superficial peroneal nerve: implications for ankle arthroscopy and for anterolateral surgical approaches to the ankle.

Ankle arthroscopic procedures offer less postoperative morbidity with faster healing times than open surgical procedures but still have associated risks. Complication rates as high as 17% have been reported. One of the most commonly reported complications is iatrogenic damage to the superficial peroneal nerve, which can result in numbness, tingling, or painful neuralgia. In the present study, we attempted to better assess the location of the superficial peroneal nerve at the ankle to improve preoperative planning and reduce complication rates. Fifty ankle specimens were dissected. A concerted effort was made to classify the location of the superficial peroneal nerve according to the Takao branching pattern, zones of the ankle, and distance to anatomic landmarks. Through our dissections, we found that most ankles have 2 nerve branches at the level of the ankle joint (Takao type II) and that the location of the superficial peroneal nerve branches at the ankle correlated directly with the ankle width. Additionally, 68% of specimens contained a nerve branch located in zone 1, where the anterolateral portal is placed, and 12% had a branch in zone 5, the location of the anteromedial portal site. The results of the present study have confirmed the wide variation in nerve location at the level of the ankle joint and serve to highlight the need for extreme caution during surgical procedures at the ankle.