Transoral and submental thyroidectomy using intraoperative nerve stimulation and indocyanin green fluorescence imaging

There is a recent proliferation of clinical studies about the minimally invasive scarless thyroid surgery. The transoral endoscopic thyroidectomy vestibular approach (TOETVA) carries a great potential for being scarless surgery via a short dissection flap. However, TOETVA has limitations in extracting larger thyroid tumours via the transoral vestibular incision and due to its potential damage to the branches of the mental nerve. The rapidly evolving surgical innovations have now introduced transoral and submental thyroidectomy (TOaST) approach that allows extraction of large thyroid tumours with less flap dissection and minimal postoperative pain. We present a 39-year-old man with a large multinodular goitre. The patient was euthyroid with moderate to severe compression symptoms of difficulty in breathing and swallowing. We performed a TOaST procedure using intraoperative neuromonitoring and indocyanin green fluorescence imaging with an uneventful recovery. This is a first case report from the middle east region that will pave the way to large clinical trials to determine the efficacy and safety of TOaST.

Comparative Study of Standard Four-Port, Three Port and Single Incision Laparoscopic Cholecystectomy Performed by a Single Surgeon in Nobel Medical College Teaching Hospital, Nepal

Introduction: Laparoscopic Cholecystectomy is a standard operative procedure for patients with gallbladder diseases and is the most common laparoscopic procedure performed worldwide. The aim of this study is to analyze the different methods of laparoscopic cholecystectomies done by a single surgeon at Nobel Medical College Teaching Hospital. Objectives: The objective and aim of this study are comparing 4 port classic Laparoscopic Cholecystectomy (4PLC), 3 port (3PLC) and Laparo-Endoscopic Single-Site Cholecystectomy (LESC) performed by a single surgeon and correlate worldwide experience with outcomes in our institution. Methodology: The study includes retrospective analysis of 8192 patients who underwent elective laparoscopic Cholecystectomy (LC) from October 2010 to July 2020 performed by the single surgeon. All cases divided into 3 groups depending on the type of LC (4PLC, 3PLC, LESC). The data included the type of the surgery, gender, age, operative time, conversion and complication rate and duration of hospital stay. Results: The hospital stays, operation time and conversion rate decreased from group I to group III. Female patients out numbered the male ones (M:F=1:4). The hospital stays (3.4 days), operation time (35 min), conversion (0.4%) and complications (0.7%) rate decreased from Group of 4PLC to Group of LESC (1.5 days, 13 min, 0.1% conversion, 0.4% complication respectively) which is true for almost all other similar studies. Conclusion: The advantages of LESC include a better cosmetic effect and reduced chance of infections. It has been postulated to be superior in scarless surgery with added benefits of lower pain level and reduced need for analgesics, shorter hospital stays, quicker return to work and lower financial expenses.

Prospective study to compare abdominal hysterectomy versus non- descent vaginal hysterectomy at a tertiary care hospital

Background: Hysterectomy can be performed by vaginal, abdominal and via laparoscopic route. In the current scenario of importance of non-invasive surgery there has been increase in interest and requirement of vaginal hysterectomy for non-prolapsed uterus i.e. Non-descent vaginal hysterectomy (NDVH) due to scarless surgery. Gynecologist across the world continue to use the abdominal approach for a large majority of hysterectomies that may be performed vaginally despite well documented evidence which says that vaginal hysterectomy do have better outcome. This study aimed to find out to compare outcomes of NDVH and Abdominal hysterectomy (AH).Methods: The study is conducted at department of Obstetrics and Gynecology, at a tertiary care hospital Gujarat, India, between the periods of May 2018 to December 2019 of 100 patients. 50 Patients who underwent hysterectomy by abdominal route are taken as study group A and 50 Patients who underwent hysterectomy by vaginal routes are taken as group B.Results: Out of 100 women we have studied, duration of surgery, intra operative blood loss, intra operative complications, postoperative morbidity and duration of hospital stay, time required to resume normal work are less in group B (NDVH).Conclusions: It can be concluded that NDVH is feasible, safe and better alternative to abdominal hysterectomy for benign gynecological conditions. It also provides greater efficacy and safety with minimal invasiveness.

Reoperative Transaxillary Approach Algorithm: Extending the Surgical Alternatives for Secondary Breast Augmentation in the Era of Scarless Surgery

Background Although the transaxillary approach (TAA) is useful in primary breast augmentation (BA) surgery, drawbacks of this technique include the need to correct complications arising from reuse of the axillary incision. Objectives The purpose of this study was to assess the outcomes of secondary BA procedures performed via the TAA in a cohort of patients operated on by a single surgeon and to provide an algorithm for reoperative TAA technique selection. Methods Sixty-two patients (122 breasts) underwent secondary TAA BA, which was indicated for capsular contracture (CC) in 35 patients (56.4%). Periods for analysis included less than 10 days, 1, 3, 6, and 12 months, and then at 2-year intervals postprocedure. Results Forty-three patients (69.3%) had a previous premuscular (PM) pocket; in 35 (81.3%) of these patients the new pocket was kept in the same position. Nineteen patients (30.7%) had a previous submuscular pocket, and 15 patients (78.9%) had the new pocket transferred to the PM plane. Ten cases of complications were observed in 8 patients (16.1%), Baker grade II/III CC in 3 (4.8%), and axillary banding in 2 (3.2%), during a mean follow-up of 72 months (range, 6-170 months). Fifty-nine patients (95.1%) were either very satisfied or satisfied with their aesthetic result. Conclusions Recent progress in surgical techniques has led to significant improvements in aesthetic outcomes following BA. The TAA can play a useful role in secondary BA cases and our results show this procedure to be useful, with acceptable complication rates, and the added bonus of avoiding additional scarring on the breast. Level of Evidence: 4

Transoral endoscopic thyroidectomy vestibular approach: early experience in a single centre

Background: Conventional open thyroidectomy is associated with a visible scar in the neck which may cause significant psychological distress to some patients, especially young women. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is an adaptation of the natural orifice transluminal endoscopic surgery (NOTES) technique to thyroid surgery and allows for a scarless surgery with minimal dissection.Methods: This study retrospectively reviewed all TOETVA surgeries performed at the department of endocrine surgery between August 2016 and July 2018. Protocol for selecting patients for this novel approach included patients with clinically benign thyroid nodules less than 6cm in diameter, with a strong preference for scarless surgery. The surgery was performed endoscopically through the inferior oral vestibule using conventional laparoscopic instruments.Results: A total of 11 patients were included. The mean size of the thyroid nodules was 3.72 cm. Hemithyroidectomy was performed in 7 patients and total thyroidectomy in 4. The median operative time was 150 minutes for hemithyroidectomy and 225 minutes for total thyroidectomy. One patient required conversion to open thyroidectomy due to excessive bleeding. Adverse effects included transient mental nerve palsy in 2 patients, temporary RLN palsy in 1 patient and temporary hpoparathyroidism in 1 patient. All 10 patients who underwent successful TOETVA reported satisfaction with the cosmetic outcome.Conclusions: TOETVA can be used to offer scar free thyroidectomy in appropriately selected patients. Attention to the anatomy of the mental nerve is essential to prevent nerve injury. Additionally the relatively longer operative time could lessen with increasing operator experience.

Use of Whey Protein as a Natural Polymer for Tissue Adhesive: Preliminary Formulation and Evaluation In Vitro

The use of sutures is still the most widely practiced solution for wound closure and tissue reconstruction; however, scarring is a common defect resulting from sutures on topical use. In some cases, the conventional sutures are unable to seal the sites where fluid and air leakage could occur. Tissue adhesives though have lower tensile strength than sutures, may make scarless surgery possible, or prevent fluid and air leakage. A product called BioGlue® (CryoLife Inc, Kennesaw, GA, USA), based on bovine serum albumin (BSA, a protein) and glutaraldehyde (GTA, crosslinker), has been approved for clinical use in the USA. Whey protein, a byproduct of cheese-making, comprised mainly of β-lactoglobulin, α-lactalbumin and BSA. Even though the molecular weight of BSA is about three times larger than the molecular of β-lactoglobulin and α-lactalbumin, all three proteins are rich in free ε-amino groups (can react with GTA) and globular proteins. This similarity make whey protein a potential candidate to replace BSA in the tissue adhesive since whey protein is abundant and much cheaper than BSA. In this study, whey protein isolate (WPI) was used as a protein polymer with GTA as a crosslinker to evaluate the feasibility of whey protein for tissue adhesive formulation. Results showed that the WPI/GTA adhesive exhibited a comparable adhesive strength to BioGlue® control.