Subtemporal Approach and Its Infratentorial Extension: Review and a Comparative Analysis of Different Techniques

Introduction Surgical resection of lesions occupying the incisural space is challenging. In a comparative fashion, we aimed to describe the anatomy and surgical approaches to the tentorial incisura and to the rostral brainstem via the intradural subtemporal approach and its infratentorial extensions. Methods Six fresh human head specimens (12 sides) were prepared for the microscopic dissection of the tentorial incisura using the intradural subtemporal approach and its infratentorial extensions. Endoscope was used to examine the anatomy of the region inadequately exposed with the microscope. Image-guided navigation was used to confirm bony structures visualized around the petrous apex. Results Standard subtemporal approach provides surgical access to the supratentorial brainstem above the pontomesencephalic sulcus and to the lateral surface of the cerebral peduncle. The linear or triangular tentorial divisions can provide access to the infratentorial space below the pontomesencephalic sulcus. The triangular tentorial flap in comparison with the linear incision obstructs the exposure of anterior incisural space and of the prepontine cistern. Visualization of the brainstem below the trigeminal nerve can be achieved by the anterior petrosectomy. Conclusion Infratentorial extension of the intradural subtemporal approach is technically demanding due to critical neurovascular structures and a relatively narrow corridor. In-depth anatomical knowledge is essential for the selection of the appropriate operative approach and safe surgical resections of lesions.

Anesthesia for Laparoscopic Surgery: Anesthetic Management and Complications

Laparoscopic surgery results in physiologic changes that encompass multiple organ systems, with respiratory, cardiovascular and neurologic and splanchnic effects. Insufflation of the peritoneum results in reduced lung volumes, atelectasis, and endobronchial migration of the endotracheal tube. Pneumoperitoneum can result in changes to venous return, cardiac output and blood pressure. Hypercapnia due to carbon dioxide gas used in insufflation can reduce cerebral perfusion pressure. Complications during laparoscopic surgery often occur during port placement and creation of the pneumoperitoneum. Problems include injury to blood vessels during trocar entry, vascular injury in the pneumoperitoneum with limited surgical access, severe bradycardia and arrhythmias due to vagal stimulation from peritoneal stretching, subcutaneous emphysema, pneumothorax, gas embolism, and complications associated with steep Trendelenburg positioning. A thorough understanding of the physiologic changes associated with laparoscopic procedures and recognition of potential complications will facilitate in optimal patient care. This review contains 4 figures, 1 table and 52 references Keywords: Laparoscopy; laparoscopic surgery; carbon dioxide; pneumoperitoneum; capnothorax; general anesthesia; subcutaneous emphysema; insufflation

Adjunctive Effect of Systemic Antibiotics in Regenerative/Reconstructive Periodontal Surgery—A Systematic Review with Meta-Analysis

Background and Objective: Systemic antibiotics (AB) are often used in conjunction with regenerative/reconstructive periodontal surgery of intrabony defects and furcations; however, their potential benefits have not been systematically assessed. Materials and Methods: Data were retrieved from two recent systematic reviews (a total of 105 randomized clinical trials (RCTs) on clinical and radiographic outcomes in intrabony defects (ID) and molars with furcation involvement (FI) treated by surgical access with regenerative techniques. Pair-wise meta-analysis of RCTs with and without AB was performed. Meta-regressions from single-arm (subgroup) RCTs including study arms with or without adjunctive AB were also conducted. Results: No statistically significant benefits of systemic AB with regard to PPD, CAL and bone gain were detected in ID by pair-wise meta-analysis. Meta-regression revealed increased PPD reduction (−0.91 mm, 95% CI = −1.30; −0.51, p < 0.001), CAL gain (−0.92 mm, 95% CI = −1.32; −0.52, p < 0.001) and bone gain (−1.08 mm, 95% CI = −1.63; −0.53, p < 0.001) in ID but not in any of the outcomes in FI for arms treated with AB vs. study arms treated with no AB. No clear differences in adverse events were detected between AB and non-AB groups. Conclusion: There is only weak indirect evidence that AB may provide additional benefits in terms of clinical improvements in the regenerative/reconstructive periodontal surgery of intrabony defects and no evidence for a benefit in furcations. Until new data are gained and in the context of antibiotic stewardship, it may be questionable to justify the adjunctive use of systemic antibiotics.

A modified endaural approach to the fractured condyle: a clinical case report

The authors present a modified endaural incision with a caudal extension for surgical access to the mandibular condyle. The approach combined the advantages of good scar cosmesis and sufficient access to the surgical site for optimal placement of the osteosynthesis with lesser risk of nerve damage.

ROLE OF ACCESS OSTEOTOMY IN HEAD AND NECK LESIONS – A REVIEW

The surgical resection of the head and neck lesions summarizes the principles, classifications, applications, complications, and post-operative care of osteotomy with the standard protocols performed safely. It often poses a great surgical challenge due to the anatomical complexity, difficulty in accessibility, and proximity of vital structures. A multidisciplinary approach is often required in these situations for their better exposure to provide surgical access. Access osteotomy is the choice and type for these head and neck lesions, which are most often based on the anatomic extent of the lesion, vascularity of the lesion, and involvement of neurovascular structures in and around it. The literature search using Medline from the year 1986 to 2019 were performed and textbooks were also collected by hand search from the same period. The role of aggressive surgical resection has not been established for malignant head and neck lesions with the technical feasibility and its efficacy for specific tumor types must be defined by the future studies. Thus, we would like to conclude that access osteotomy allows the surgeon a better view and an access of the surgical field to resect the tumor completely with safer margins, preserving the vital structures, pre-operative functions, and reducing post-operative complications.

Case Report: Robotically Assisted Excision of Cystic Tumor Located in a Difficult to Access Area in the Liver

Introduction: Cystic liver lesions may be benign cysts, parasitic infestations, or malignant tumors requiring surgical resection. Hilar location and relation to major vasculature present challenges in conventional surgical access and resection.Materials and Methods: We describe totally robotic excision of a cystadenoma in a 55-year-old woman without complication. Time points in the accompanying video (https://youtu.be/Tn_QPgpSHA4) are embedded within the text.Results: Advantages of the robotic technique lie in overcoming the natural restriction of conventional laparoscopic instruments, easier repair, and control of intraoperative vascular injuries using EndoWrist® instruments, ergonomic dissection close to major vasculature and reduced intraoperative blood loss as dissection is easier.Discussion: Indications for robotic surgery included the large size of the cystic lesion, its intrahepatic location, and compression of the inferior vena cava (IVC) and right and middle hepatic veins. Had robotic removal of the lesion not been feasible, the entire lobe of the liver would have required resection.

426 Percutaneous or surgical access for transfemoral transcatheter aortic valve implantation: a propensity matched analysis of a multicentre registry

Aims The transfemoral (TF) approach appeared to be the safest and the broadest used approach in TAVI, characterized by a lower rate of periprocedural bleedings and vascular complications and is currently recommended by the guidelines as a first line approach when feasible. If in the early experience TF access was achieved using a surgical cutdown approach, through the last years, there has been increasing evidence of the safety and efficacy of a fully percutaneous approach over a surgical access, albeit available evidences are controverting and mostly including first generation prostheses and high risk patients. The aim of the study is to compare percutaneous and surgical access in a large, real-word, multicentre of TF TAVI. Methods and results Consecutive patients undergoing successful TF TAVI were prospectively enrolled in local clinical registries of five high volume centres in Italy: IRCCS Ospedale Policlinico San Martino (Genoa), IRCCS Policlinico San Donato (Milan), Città Della Salute e della Scienza, (Turin), Ospedale Niguarda Ca’ Granda (Milan), Magna Graecia University, (Catanzaro), between January 2014 to December 2019. Univariate and multivariate analysis using IPTW were performed. A total of 1946 TF TAVI patients (female 42.8%) were prospectively included. Patients underwent surgical access had a significantly higher surgical risk (STS score of 8.9 vs. 6.4, P &lt; 0.001, and EuroSCORE of 15.1 vs. 8.7, P &lt; 0.001, respectively). Overall survival was comparable between the two groups (HR: 1.14, 95% CI: 0.76–1.71). Patients who underwent surgical access experienced more VARC-2 major and VARC-2 minor vascular complications (13% vs. 7%, P = 0.003 and 11% vs. 6.1%, P = 0.007, respectively) and more VARC-2 major/life threatening and minor bleeding (27.4% vs. 17.8, P = 0.001, and 9.6% vs. 2.1%, P &lt; 0.001, respectively). After IPTW adjustment, surgical access was associated with an increased risk of major vascular complications (HR: 3.32, 95% CI: 1.84–5.97), minor bleeding (HR: 4.24, 95% CI: 1.16–15.54) and stage 2–3 AKI (HR: 2.60, 95% CI: 1.07–6.33). Conclusions The performance of the percutaneous transfemoral TAVI approach was safe and feasible and resulted in fewer major vascular complications, bleedings and AKI than the surgical femoral isolation. Procedural time and hospital length were also lower in the percutaneous group. Routine application of the percutaneous approach might reduce acute complications in patients undergoing transfemoral TAVI and reduce procedural time and hospital length.

Emergency Surgery Admissions and The COVID-19 Pandemic: Did The First Wave Really Change Our Practice? Results of An ACOI/WSES International Audit On 6263 Patients.

IntroductionThe COVID-19 pandemic is having a deep impact on emergency surgical services, with a significant reduction of patients admitted into emergency surgical units world widely. Reliable figures of this reduction have not been produced yet. Our international audit aimed at giving a precise snapshot of the absolute and relative changes of emergency surgical admissions at the outbreak of the pandemic. Materials and methodsDatasets of patients admitted as general surgical emergencies into 45 internationally distributed emergency surgical units during the months of March and April 2020 (Covid-19 pandemic outbreak) were collected and compared with those of patients admitted into the same units during the months of March and April 2019 (pre-Covid-19). Primary endpoint was to evaluate the relative variation of the presentation symptoms and discharge diagnoses between the two study periods. Secondary endpoint was to identify the possible change of therapeutic strategy during the same two periods. ResultsForty-four centres participated sent their anonymised data to the study hub, for a total of 6263 patients. Of these, 3810 were admitted in the pre-Covid period and 2453 in the Covid period, for a 35.6% absolute reduction. The most common presentation was abdominal pain, whose incidence did not change between the two periods, but in the Covid period patients presented less frequently with anal pain, hernias, anaemia and weight loss. ASA 1 and low frailty patients were admitted less frequently, while ASA>1 and frail patients showed a relative increase. The type of surgical access did not change significantly, but lap-to-open conversion rate halved between the two study periods. Discharge diagnoses of appendicitis and diverticulitis reduced significantly, while bowel ischaemia and perianal ailments had a significant relative increase.ConclusionsOur audit demonstrates a significant overall reduction of emergency surgery admissions at the outbreak of the Covid-19 pandemic with a minimal change of the proportions of single presentations, diagnoses and treatments. These findings may open the door to new ways of managing surgical emergencies without engulfing the already busy hospitals.