Hinchey III Diverticulitis in a 31-Year-Old Patient With Williams Syndrome: A Case Report.

Williams syndrome was first reported by Williams and Beuren in 1961-1962. It is a genetic disorder that is caused by a sporadic microdeletion of chromosome 7, which includes the elastin gene. The development of gastrointestinal pathology, such as diverticular disease, is associated with the deletion of this specific gene. Almost one-third of patients with Williams syndrome develop diverticular disease. The first episode of diverticulitis appears in 8% of patients, diagnosed with Williams syndrome, before the age of 40. According to the literature, in the case of complicated diverticulitis (Hinchey III) in patients with WS, the treatment is mainly surgical resection of sigmoid and colostomy (Hartmann procedure) or anastomosis. We present an interesting case with a 31-year-old male, with Williams syndrome and Hinchey III diverticulitis, who underwent laparoscopic lavage and primary closure of the perforation. To our knowledge, this is the first case in literature that a patient with Williams syndrome and complicated diverticulitis (Hinchey III) was treated this way and the results until now are encouraging.

Assessment and Techniques for Endoscopic Closure.

Endoscopic closure is an essential technique to perform safe advanced endoscopy. Without appropriate closure of a defect, patients can experience spillage of fecal contents into the peritoneal cavity resulting in abdominal sepsis. The essential components to performing endoscopic closure are assessing the defect appropriately and choosing the correct closure technique. Assessing the defect involves five separate elements: timing, size, depth, shape, blood flow, and location in the colon or rectum. Understanding how each of these elements contributes toward a successful closure allows an endoscopist to choose the proper technique for closure. There have been many types of closure techniques described in the literature but the most common are through the scope clips, over the scope clips, and endoscopic suturing. There are advantages and disadvantages of each of these closure techniques. In this manuscript, we will discuss these common techniques as well as some additional techniques and the situations where they can be employed.

Evaluation of orthobiological ozonized platelet-rich plasma therapy post-arthroscopic suturing and lone partial meniscectomy in the treatment of meniscal tears within degenerative knee osteoarthritis.

BACKGROUND: Knee joint osteoarthritis (OA)-related meniscal tears are still sometimes treated in centers by arthroscopic partial meniscectomy (APM), which is then followed by a solitary physical therapy regimen. OBJECTIVE: The present study was conducted to compare the efficacy of intra-articular injection of ozonized platelet-rich plasma (PRP) and hyaluronic acid following arthroscopic suturing, and APM to treat meniscal tear degenerative type. METHODS: In a randomized trial of prospective comparative research, 104 patients, all of whom had meniscal tears due to OA of the knee, were randomly divided into two groups. The participants in Group A (55 patients) were given intra-articular ozonized PRP and hyaluronate therapeutics, following arthroscopic suturing of meniscal tear treatment (ASMT) of degenerative knee joint OA. Group B (49 patients) was prepared for APM alone. Both groups were followed by physical therapy and a follow up visit throughout 12, 24, and 36 months. The WOMAC and Lequesne scores were evaluated. RESULTS: At every follow up visit for 6, 12, and 24, months, there was a significant decline in the mean of WOMAC and Lequesne scores in Groups A and B relative to baseline. Additionally, Group A significantly (P<0.0001) outperformed Group B at 12, 24, and 36 months for both Lequesne's and WOMAC scores. There were infection, stiffness, and widespread OA knee degeneration detected in Group B while no serious adverse effects were observed in Group A. CONCLUSION: The study's findings demonstrated that physical and intra-articular orthobiological ozonized PRP and hyaluronate therapies were more effective than APM in treating degenerative knee joint OA.

[Laparoscopic repair for perforated ulcer]. / Videolaparoskopicheskii sposob ushivaniya perforativnoi yazvy.

OBJECTIVE: To improve the immediate postoperative results in patients with perforated ulcers. MATERIAL AND METHODS: The study enrolled 25 patients with perforated peptic ulcer (diameter of perforation <8 mm). Mean age of patients was 39 years (range 24-56), perforation size - 5.92 mm (range 3-8). RESULTS: Mean surgery time was 59.8 min (range 50-85). There were no intraoperative and postoperative complications. All patients were discharged. CONCLUSION: The proposed method of repair for perforated gastric ulcers is simple, effective, safe and may be recommended for clinical practice.

The Effect of a Horizontal Apical Mattress Suturing Technique on the Width and Thickness of the Keratinized Mucosa After Dental Implant Surgery: A Cohort Study.

Introduction There is general agreement that a thick zone of the keratinized tissues around implants promotes accurate prosthetic procedures, permits oral hygiene maintenance, resists recession, and enables esthetic blending with surrounding tissues. A new procedure called Choukroun's technique has been suggested, and it consists of a combination of horizontal apical mattress suture with regular suture to increase the keratinized tissue in the mandibular arch during the first stage after implantation. The proposed procedure has not been evaluated yet in a cohort of patients. Therefore, this prospective study aimed to evaluate the impact of Choukroun's technique on the width and thickness of the keratinized gingiva after oral surgery. Materials and methods A one-group prospective cohort study was conducted on patients referred to the Department of Oral and Maxillofacial Surgery at the Dental College of Al-Wataniya Private University who had been referred to undergo dental implant surgery. The inclusion criteria for the study group were as follows: patients with mandibular missing teeth, good oral health, good general health, 18-70 years old, at least 1 mm thickness of keratinized gingiva, and at least 1 mm width of the attached gingiva. A total of 14 patients aged 27-67 years were included in the study. After inserting the dental implants, the suturing was accomplished according to Choukroun's method. The width and thickness of the keratinized gingiva were assessed before surgery and at one and two months post-surgery. Repeated measures analysis of variance (ANOVA) was applied to detect significant differences between assessment times. Results The study sample comprised 14 patients, of which four were females (28.6%) and 10 were males (71.4%). Patients' ages ranged from 27 to 67 years, with a mean age of 54.86 ± 11.73 years. The surgical procedure was performed in three different regions: the upper posterior teeth with four patients (28.6%), the upper anterior teeth with three patients (21.4%), and the lower posterior teeth with seven patients (50%). The mean gingival width before surgery was 5.78 mm, whereas the mean gingival thickness was 2.82 mm. There was no significant difference between the three evaluation times in the mean gingival width (P=0.222), and there was a significant difference between the three evaluation times in the mean gingival thickness (P<0.001). The mean mean gingival thickness one month after surgery was significantly greater than its mean value before surgery (mean difference: 0.749 mm). Additionally, the mean gingival thickness two months after surgery was significantly greater than its mean value before (mean differences: 0.636 mm). Conclusions Using horizontal apical mattress sutures (Choukroun's technique) does not provide any advantage in increasing the width of the keratinized gingiva. However, it does lead to an increase in the thickness of keratinized gingiva in the surgical area. Therefore, the use of horizontal apical mattress sutures is recommended.

Efficacy and outcomes of per oral plication of the (neo)esophagus (POPE) for impaired emptying in achalasia and post-esophagectomy patients.

BACKGROUND: Per-oral plication of the (neo)esophagus (POPE) is an endoscopic procedure used to improve emptying of the defunctionalized esophagus or gastric conduit, with the hope of improving symptoms and quality of life. As this procedure has only been performed in the United States for the past 4 years, safety and efficacy have not been well established. METHODS: This is a retrospective case series for patients who underwent POPE from a single institution between 2019 and 2023. Data collected included demographics, preoperative diagnoses and treatments, imaging, endoscopic data, operative intervention, 90-day complications, and response to treatment. Quality of life and patient satisfaction data were collected by phone survey. RESULTS: Seventeen cases were identified, encompassing 13 primary procedures and 4 repeat POPEs (re-POPE). Eight patients had end-stage achalasia and 5 had impaired gastric emptying after esophagectomy with gastric conduits. Median age was 65 years and median ASA was 3, with 38.5% female patients. POPE was performed with 2-6 plication sutures in an average of 75 min. The majority of patients discharged home the same day. For the 17 procedures, there were 4 complications. Two patients required antibiotics for pneumonia, while 4 required procedural intervention. There were no deaths. Preoperative symptoms improved or resolved at initial follow up in 82.3% of patients. Four patients experienced symptom recurrence and required re-POPE, 1 with achalasia and 3 with gastric conduits. Although all achalasia patients had an "end-stage esophagus," none have required esophagectomy since the introduction of POPE. CONCLUSIONS: POPE is an endoscopic procedure that is efficacious in relieving emptying difficulties for the end-stage esophagus and gastric conduit. It may obviate the need for esophagectomy or conduit replacement. Also, it can be repeated in select patients. While the risk profile of complications is favorable compared to alternative operations, patients with gastric conduits are at higher risk.

[Assessment tool's validation study for a simulation-based skin suturing skill]. / Étude de validation d'une grille d'évaluation d'un exercice de suture cutanée en simulation.

CONTEXT: Health simulation is a recognized educational method for teaching and validating surgical procedural skills. The latter requires the development of adapted assessment tools, reaching different validity criteria. The aim of this study was to validate a multimodal assessment tool for a complex skin suturing exercise, combining a manual knot, an intradermal linear suturing and a needle holder tied knot. METHODOLOGY: The suturing exercise was realized on a synthetic skin model by voluntary participants after having obtained their written consent, including 9 postgraduate medical students, 40 surgical residents of different levels of experience, and a group of 9 senior surgeons. The multimodal assessment tool (MAT) combined a checklist, a speed score and a global rating scale. Each exercise was scored by two evaluators. Medical students' performances were filmed anonymously so that they could be scored iteratively. Content validity was tested through a satisfaction questionnaire randomly completed by participants. RESULTS: The MAT was considered relevant or very relevant by 98% of the participants, with a better appreciation for the checklist than for the global rating scale. Internal consistency was strong with a Cronbach α coefficient at 0.78, and a good correlation between the results of the checklist and the global rating scale (r=0.79, P<0.0001). The MAT showed continuous improvement in mean scores from 34.4±3.6 for novices to 47.4±2.5/50 points for experts, passing through three intermediate levels groups, and allowed for significant discrimination between groups. The MAT was reliable, with a coefficient of correlation set at 0.88 for intra-observer reliability, and 0.72 for inter-observer reliability. On sub score analysis, the global rating scale and the speed score better discriminated between groups than the checklist, the latter moreover showing slightly lower reliability than the global rating scale. CONCLUSION: Despite its banality in any surgeon's practice and the fact that it is taught from the 2nd cycle of medical studies, suturing and its technical components have rarely been the subject of publications dedicated to the validation of specific assessment tools. Hence, this work on the MAT and its sub scores made it possible to validate them on many validity and reliability criteria. They can therefore be proposed to surgical teachers for evaluating a complex suturing exercise, with a checklist that is easier to use even for novices and a global rating scale showing better discrimination capacity.

Fundus-to-Antrum Ratio Measured with Fluoroscopy within One Week after Endoscopic Sleeve Gastroplasty Predicts Total Body Weight Loss over Time.

Background and Aims: Endoscopic sleeve gastroplasty (ESG) is a minimally invasive bariatric procedure to induce weight loss through restrictive physiology. This study was designed to evaluate the fluoroscopic measurement of gastric dimensions after ESG as a predictor of Total Body Weight Loss (TBWL) over time. Methods: Post-ESG patients were enrolled prospectively between August 2013 and August 2019. An upper gastrointestinal (GI) fluoroscopy was obtained within 7 days after the procedure. Two blinded, independent radiologists reviewed fluoroscopic images and measured the gastric lumen transverse diameter in three separate areas of the fundus, body, and antrum. The primary outcome was achieving a TBWL of ten percent or more after ESG. Results: In total, 162 patients were included in the analysis (65% female) and had a mean body mass index (BMI) of 39 ± 6 at baseline. Patients had a mean maximum TBWL of 16.5 ± 8.3%. Respectively, 92%, 75%, and 50% of patients achieved a TBWL of 5%, 10%, or 15% or more. The mean post-procedural UGI gastric fundus/antrum transverse measurement ratio was 1.2 ± 0.6. A higher fundus-to-antrum ratio was significantly associated with a TBWL of 10% or more during follow-up in the multivariable model (OR 2.49, 95% CI 1.31-4.71; p-value 0.005). The prediction score based on the fundus-to-antrum ratio hd an area under the ROC curve of 0.79 (95% CI 0.75-0.83) for predicting a TBWL of 10% or more during follow-up. Conclusions: Measuring gastric the fundus/antrum ratio within one week of endoscopic sleeve gastroplasty (ESG) is a consistent and independent predictive measure of sustained TBWL during long-term follow-up.

Comparison of long-term outcomes of laparoscopic percutaneous internal ring suturing and classic open approach for inguinal hernia repair in children.

INTRODUCTION: Inguinal hernia repair is one of the most common surgeries in children. Recently, the use of minimally invasive techniques for inguinal hernia repair has increased in children. Laparoscopic percutaneous internal ring suturing (PIRS) is a technique described for paediatric inguinal hernia repair. The primary objective of this study is to demonstrate the efficacy and reliability of PIRS in paediatric patients through a comparative analysis with an open method. METHODS: Between January 2017 and June 2023, records of patients who underwent surgery for inguinal hernia were retrospectively reviewed. In total 126 patients were included in the study. They were divided into two groups: 33 patients underwent PIRS (group 1) and 93 patients underwent open repair (group 2). Operation time, cost and complications were compared. RESULTS: The mean age of the 126 patients was 3.23 ± 2.4 years. The mean unilateral operative time was 25.13 ± 5.32min in group 1 and 30.28 ± 4.73min in group 2, and there was a statistically significant difference in operative time (p < 0.001). Two patients in group 1 underwent surgery owing to patent processus vaginalis, whereas three patients in group 2 underwent surgery owing to metachronous hernia. There were no major complications such as bleeding requiring surgical intervention or conversion to an open approach during surgery in group 1. No recurrent hernia was observed in any of the 126 patients. CONCLUSIONS: PIRS offers a safe, easy-to-learn method with low complication rates. PIRS has a distinct advantage over open surgical repair because of its capacity to evaluate the contralateral inguinal ring.

Percutaneous Internal Ring Suturing for Inguinal Hernia Repair in Children: Retrospective Cohort of 714 Patients with Minimum 3-Year Follow-Up.

Background and Objectives: Despite numerous described techniques, laparoscopy has yet to replace open surgery as the gold standard for inguinal hernia (IH) repair in children. This may be due to many variables, including the lack of long-term follow-up and concern for increased recurrence. In this study, we present our long-term follow-up data on children undergoing percutaneous internal ring suturing (PIRS) for IH repair. Materials and Methods: This retrospective cohort study included children who underwent PIRS for IH between May 2013 and May 2021 at three tertiary care institutions, with at least three years of follow-up. Age at surgery, side of IH, presence of contralateral patent processus vaginalis, surgical and anesthesia time, and complications were noted. Parents were contacted to enquire about long-term complications, such as recurrence. Results: Long-term follow-up (average 6.9 ± 2.3 years) was available for 714 patients. For unilateral and bilateral procedures, the average surgical time was 13.6 ± 5.4 and 19.9 ± 3.0, and the average anesthesia time was 27.7 ± 12.9 and 33.9 ± 14.1 min, respectively. Complications were seen in 0.84% of patients and 1.2% of procedures, and recurrence was observed in 0.98% of patients and 0.78% of procedures. Conclusions: Our study, with a nearly 7-year follow-up, provides substantial evidence that PIRS is a safe and effective technique for IH repair in children, with low recurrence and complication rates. Despite the study's retrospective nature and limited sample size, it contributes valuable data supporting the use of PIRS in pediatric IH repair.

Major Complication Caused by Inguinal Hernia Recurrence After Percutaneous Internal Ring Suturing Procedure in a Patient With Loeys-Dietz Syndrome: A Case Report.

Inguinal hernia repair is one of the most frequently performed procedures in pediatric surgery. Treatment methods include classical open repair and laparoscopic approach. In this report we analyze a case of a 14-month-old boy with Loeys-Dietz syndrome treated for an inguinal hernia with laparoscopic percutaneous internal ring suturing (PIRS). Two weeks post-operatively the patient was diagnosed with a recurrence of the hernia complicated by an intestine strangulation. As a re-operation of the hernia, the Lichtenstein method was applied successfully. We analyzed the literature to determine the safety and possible contradictions of the PIRS procedure, with particular emphasis on patients with comorbidities such as connective tissue disorders. We conclude that in the PIRS procedure, despite its safety, feasibility and low complication rate in healthy patients, too few studies were made to draw similar conclusions for patients with comorbidities such as connective tissue disorders.

Self-assessment, and not continuous training, improves basic open suturing skills.

BACKGROUND: To develop and maintain suturing skills, clinical exposure is important. When clinical exposure cannot be guaranteed, an adequate training schedule for suturing skills is required. This study evaluates the effect of continuous training, 'reflection before practice' and self-assessment on basic open suturing skills. METHODS: Medical students performed four basic suturing tasks on a simulation set up before ('pre-test') and after their surgical rotation ('after-test'). Participants were divided in three groups; the 'clinical exposure group' (n = 44) had clinical exposure during their rotation only, the 'continuous training group' (n = 16) completed a suturing interval training during their rotation and the 'self-assessment group' (n = 16) also completed a suturing interval training, but with the use of reflection before practice and self-assessment. Parameters measured by a tracking system during the suturing tasks and a calculated 'composite score' were compared between groups and test-moments. RESULTS: A significantly better composite score was found at the after-test compared to the pre-test for all groups for all basic suturing tasks (0.001 ≤ p ≤ 0.049). The self-assessment group scored better at the pre-test than the other two groups for all tasks, except for 'knot tying by hand' (0.004 ≤ p ≤ 0.063). However, this group did not score better at the after-test for all tasks, compared to the other two groups. This resulted in a smaller delta of time ('transcutaneous suture', p = 0.013), distance ('Donati suture' and 'intracutaneous suture', 0.005 ≤ p ≤ 0.009) or composite score (all tasks, except for knot tying by hand, 0.007 ≤ p ≤ 0.061) in the self-assessment group. CONCLUSION: Reflection before practice and self-assessment during continuous training of basic open suturing tasks, may improve surgical skills at the start of the learning curve.

Robotic hepaticojejunostomy training in novices using robotic simulation and dry-lab suturing (ROSIM): randomized controlled crossover trial.

BACKGROUND: Robotic suturing training is in increasing demand and can be done using suture-pads or robotic simulation training. Robotic simulation is less cumbersome, whereas a robotic suture-pad approach could be more effective but is more costly. A training curriculum with crossover between both approaches may be a practical solution. However, studies assessing the impact of starting with robotic simulation or suture-pads in robotic suturing training are lacking. METHODS: This was a randomized controlled crossover trial conducted with 20 robotic novices from 3 countries who underwent robotic suturing training using an Intuitive Surgical® X and Xi system with the SimNow (robotic simulation) and suture-pads (dry-lab). Participants were randomized to start with robotic simulation (intervention group, n = 10) or suture-pads (control group, n = 10). After the first and second training, all participants completed a robotic hepaticojejunostomy (HJ) in biotissue. Primary endpoint was the objective structured assessment of technical skill (OSATS) score during HJ, scored by two blinded raters. Secondary endpoints were force measurements and a qualitative analysis. After training, participants were surveyed regarding their preferences. RESULTS: Overall, 20 robotic novices completed both training sessions and performed 40 robotic HJs. After both trainings, OSATS was scored higher in the robotic simulation-first group (3.3 ± 0.9 vs 2.5 ± 0.8; p = 0.049), whereas the median maximum force (N) (5.0 [3.2-8.0] vs 3.8 [2.3-12.8]; p = 0.739) did not differ significantly between the groups. In the survey, 17/20 (85%) participants recommended to include robotic simulation training, 14/20 (70%) participants preferred to start with robotic simulation, and 20/20 (100%) to include suture-pad training. CONCLUSION: Surgical performance during robotic HJ in robotic novices was significantly better after robotic simulation-first training followed by suture-pad training. A robotic suturing curriculum including both robotic simulation and dry-lab suturing should ideally start with robotic simulation.

Lidocaine spray vs mepivacaine local infiltration for suturing 1st/2nd grade perineal lacerations: a randomised controlled non-inferiority trial.

BACKGROUND: Perineal lacerations are a very common complication of post-partum. Usually, the repair of 1st and 2nd-grade lacerations is performed after the administration of local anesthesia. Despite the great relevance of the problem, there are only a few studies about the best choice of local anesthetic to use during suturing. We performed a randomised controlled trial to evaluate the efficacy and safety of the use of a local anesthetic spray during the suturing of perineal lacerations in the post-partum. METHODS: We compared the spray with the standard technique, which involves the infiltration of lacerated tissues, using the NRS scale. 136 eligible women who had given birth at University Hospital of Udine were enrolled and randomly assigned to receive nebulization of Lidocaine hydrochloride 10% spray (experimental group) or subcutaneous/submucosal infiltration of mepivacaine hydrochloride (control group) during suturing of perineal laceration. RESULTS: The lacerations included 84 1st-grade perineal traumas (61.7%) and 52 2nd-grade perineal traumas (38.2%). All the procedures were successfully completed without severe complications or serious adverse reactions. There were no statistically significant differences between the two groups in terms of blood losses or total procedure time. Moreover, there were no statistically significant differences in terms of NRS to none of the intervals considered. Regarding the application of the spray in the B group, in 36 cases (52.9%) it was necessary to improve the number of puffs previously supposed to be sufficient (5 puffs). Just in 3 cases, an additional injection was necessary (4.4%). CONCLUSIONS: Our study demonstrates that lidocaine spray alone can be used as a first line of local anesthetic during the closure of I-II-grade perineal lacerations, as it has comparable efficacy to mepivacaine infiltration. TRIAL REGISTRATION: The trial was recorded on https://clinicaltrials.gov . Identification number: NCT05201313. First registration date: 21/01/2022. Unique Protocol ID: 0042698/P/GEN/ARCS.

Concurrent validity of objective assessment by finger tracking for open surgical suturing training.

BACKGROUND: The aim of this study is to evaluate whether the parameters 'time' and 'distance', measured by SurgTrac, correlate with the assessment of the same skills by blinded experts. METHODS: Basic open suturing tasks were executed by medical students. SurgTrac software measured objective parameters by tracking fingers. The executed tasks were recorded by a tablet and additionally assessed by a blinded expert with a Competency Assessment Tool-form (CAT-form). A Pearson's correlation was used to investigate the correlation between the parameters and the outcomes of the expert assessment. RESULTS: A strong correlation between the measured parameters of SurgTrac and the expert-assessment was found for knot tying by hand (r â€‹= â€‹-0.703) and vertical mattress suture (r â€‹= â€‹-0.644) and a moderate correlation for transcutaneous suture (r â€‹= â€‹-0.555) and intracutaneous suture (r â€‹= â€‹-0.451). CONCLUSION: The use of finger tracking by SurgTrac showed a good concurrent validity for the basic open suturing tasks knot tying by hand, transcutaneous suture and vertical mattress suture.

First experiences with automated annular suturing device in totally endoscopic aortic and mitral valve replacement.

OBJECTIVES: To overcome some of the challenges of endoscopic minimally invasive valve surgery, an automated annular suturing device has been used in aortic and mitral valve replacement surgeries. The current study investigates early clinical outcomes of patients who received aortic or mitral valve replacement with the help of the RAM® device as first experiences in minimally invasive valve surgery. METHODS: Between September 2020 and June 2023, 66 consecutive patients (mean age 61.8 ± 11 years) underwent endoscopic minimally invasive aortic or mitral valve replacement through right anterior mini-thoracotomy at 2 cardiac surgery referral centres in Germany. The RAM® device was used in all Patients. 3.5 and 5.0 sizes were used in 16.7% and 83.3% of patients, respectively. Aortic, mitral and double valve surgery was performed in 81.8%, 15.2% and 1.5% of patients, respectively. Clinical data were prospectively entered into our institutional database. RESULTS: Cardiopulmonary bypass time and cross-clamping time were 97.9 ± 20.9 and 66 ± 15.7 min, respectively. Intensive care unit and hospital stays were 1 [1-2] and 9 [7-13] days, respectively. No paravalvular leak and no other intraoperative complications occurred. 30-day and in-hospital mortality were zero. Conversion to sternotomy occurred in 1 (1.5%) patient due to bleeding. CONCLUSIONS: The usage of the RAM® device is a safe, feasible and effective approach to the endoscopic implantation of aortic or mitral valves and yield excellent early outcomes. Larger size studies are needed to evaluate the efficacy and safety of RAM® device.

Vaginal Vault Closure Following Total Laparoscopic Hysterectomy: Laparoscopic versus Conventional Technique - A Comparative Study.

Objectives: Vault closure is the final step to hysterectomy, protecting the abdominal cavity from the exterior environment. Thus, closure becomes crucial in preventing ascend of infection to the peritoneal cavity. Our study aims to compare vault closure between laparoscopic and vaginal routes, their operating time, and postoperative complications. Materials and Methods: The ambispective comparative study was done in a tertiary care teaching center from June 2016 to December 2022. Three hundred and forty-four patients were included in the study that underwent a total laparoscopic hysterectomy. Interventions - Patients who had laparoscopic vault closure were in Group 1 (N = 198) and those who had vaginal closure were in Group 2 (N = 146). The results were compared. It included age, body mass index of the patient, the indication of surgery, intraoperative blood loss, size of the uterus, time taken during vault closure, and postoperative complications. Results: The time taken by laparoscopic vault repair was significantly less than vaginal repair (19.7 ± 13.3 min vs. 30.1 ± 6.6 min, P < 0.001). There was postoperative vault infection (2.7%), vault hematoma (1.3%), and no vault prolapse seen in vaginal repair. The organisms isolated were mainly Pseudomonas aeruginosa, Escherichia coli, and Klebsiella. Conclusion: Laparoscopic vault closure has shown significantly improved results compared to vaginal route repair.

Graft Suturing Method Affects on Graft Diameter in Hamstring-Based Anterior Cruciate Ligament Reconstruction.

INTRODUCTION:  Various benefits of needleless suture loop techniques in anterior cruciate ligament reconstruction graft preparation have been discussed, yet their impact on graft diameter remains unexplored. We hypothesized that the suture loop technique would reduce the graft diameter compared to the conventional locking suture technique. METHODS:  Fifty-seven patients whose grafts were made with the Krackow stitch (group K) and 54 patients with the suture loop (group SL) were analyzed retrospectively. (1) The distal (sutured side) diameter of each anteromedial bundle and posterolateral bundle was compared to the proximal (non-sutured side) diameter, and (2) the average of the proximal and distal graft diameters in each group was calculated. RESULTS:  In group K, 78.9% of anteromedial bundles and 40.3% of posterolateral bundles exhibited a larger distal diameter than the proximal, while in group SL, 42.6% of anteromedial bundles and 3.7% of posterolateral bundles showed a larger distal diameter. In both bundles, there were significantly fewer grafts with larger distal diameters in group SL (p < 0.001). The mean distal diameter of anteromedial bundles was smaller in group SL (6.33 ± 0.43 mm vs. 6.07 ± 0.43 mm, p < 0.005). Consequently, the distal cross-sectional area of anteromedial bundles in group SL was 8% smaller than that in group K. CONCLUSION:  The use of the suture loop technique resulted in a significantly smaller distal diameter of the anteromedial bundle. This reduces the size of the tibial tunnel and may contribute to a reduction in potential damage to adjacent structures.

Submucosal Trans-Septal Suturing Technique After a Septal Extension Graft with Porous High-Density Polyethylene: A Technical Report.

BACKGROUND: Porous high-density polyethylene (pHDPE) is an alternative material for a septal extension graft (SEG) in oriental rhinoplasty when autologous cartilage is limited. Although nasal packing (NP) and trans-septal suturing (TSS) techniques are routine procedures to obviate the dead space after septoplasty, they are associated with certain discomforts and complications. OBJECTIVE: To investigate the application of a submucosal trans-septal suturing (STSS) technique after SEG with pHDPE. METHODS: A prospective study was conducted on 60 female participants who underwent SEG with pHDPE. The participants were randomly divided into the NP group and STSS group. The extra surgical duration of NP and STSS, pain, nasal obstruction, and sleeping disturbance as well as postoperative complications were recorded and compared between groups. RESULTS: No significant difference was found between group NP and group STSS in terms of mean age. The mean extra surgical duration of group STSS was significantly longer than group NP. There were significant higher pains of group NP at 24 hours and 48 hours postoperatively, compared with group STSS. The NP group also experienced significantly more nasal obstruction and sleep disturbance within 48h postoperatively compared to the STSS group. There was one infection in each group, minor bleeding in two NP patients, and one STSS patient. There was no major bleeding, hematoma, graft exposure, or septal perforation in both groups. CONCLUSION: Although STSS needs a longer extra surgical duration than NP, it significantly improves the patient's postoperative comfort with a faster return to normal respiration compared to NP. LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Immersive virtual reality as a surgical training tool: A cohort study.

Background: Few studies have studied the efficacy of using immersive virtual reality (iVR) to teach surgical skills, especially by using real-world iVR recordings rather than simulations. This study aimed to investigate whether viewing 360° iVR instructional recordings produces greater improvements in basic suturing skills of students without prior medical training, beyond traditional methods like reading written manuals or watching 2D instructional videos. Materials and methods: This was a partially blinded randomized cohort study. 44 pre-university students (aged 17) were randomized equally to either the written instruction manual, 2D instructional video, or iVR recordings. All students first watched a silent 2D demonstration video of the suturing task, before attempting to place three simple interrupted sutures on a piece of meat as a baseline. The time taken for the first attempt was recorded. Students were then given an hour to train using their allocated modality. They attempted the suturing task again, and timings were re-recorded. Four blinded surgically-trained judges independently assessed the quality of the stitches placed both pre and post-intervention. One-way analysis of variance tests (ANOVAs) and independent two-sample t-tests were used to determine the effect of training modality on improvements in suturing scores and time taken to complete suturing from pre to post-training. Results: For suturing scores, the iVR group showed significantly larger score improvements than the Written Manual group (p = 0.031, Cohen's D = 0.92), while this iVR advantage was less pronounced when compared with the 2D Video group (p = 0.16, Cohen's D = 0.65). Similarly for time taken to complete suturing, the iVR group had significantly larger time improvements than the Written Manual group (p = 0.045), although this difference was less robust compared to the 2D Instructional Video group (p = 0.34). Conclusion: This study demonstrates that iVR training using real-world 360° instructional recordings produced significantly greater training gains in suturing scores and efficiency compared to reading written text. iVR training also led to larger training gains in both outcome measures than viewing 2D instructional videos, although the differences between them did not reach statistical significance.