Technique for inguino-femoral lymph node dissection in vulvar cancer: an international survey

BackgroundVulvar cancer is a rare disease and despite broad adoption of sentinel lymph node mapping to assess groin metastases, inguino-femoral lymph node dissection still plays a role in the management of this disease. Inguino-femoral lymph node dissection is associated with high morbidity, and limited research exists to guide the best surgical approach.ObjectiveTo determine international practice patterns in key aspects of the inguino-femoral lymph node dissection technique and provide data to guide future research.MethodsA survey addressing six key domains of practice patterns in performing inguino-femoral lymph node dissection was distributed internationally to gynecologic oncology surgeons between April and October 2020. The survey was distributed using the British Gynecological Cancer Society, the Society of Gynecologic Oncology, authors' direct links, the UK Audit and Research in Gynecology Oncology group, and Twitter.ResultsA total of 259 responses were received from 18 countries. The majority (236/259, 91.1%) of respondents reported performing a modified oblique incision, routinely dissecting the superficial and deep inguino-femoral lymph nodes (137/185, 74.1%) with sparing of the saphenous vein (227/258, 88%). Most respondents did not routinely use compression dressings/underwear (169/252 (67.1%), used prophylactic antibiotics at the time of surgery only (167/257, 65%), and closed the skin with sutures (192 74.4%). Also, a drain is placed at the time of surgery by 243/259 (93.8%) surgeons, with most practitioners (144/243, 59.3%) waiting for drainage to be less than 30–50 mL in 24 hours before removal; most respondents (66.3%) routinely discharge patients with drain(s) in situ.ConclusionOur study showed that most surgeons perform a modified oblique incision, dissect the superficial and deep inguino-femoral lymph nodes, and spare the saphenous vein when performing groin lymphadenectomy. This survey has demonstrated significant variability in inguino-femoral lymph node dissection in cases of vulvar cancer among gynecologic oncology surgeons internationally.

A modified oblique incision in hamstring tendon graft harvesting during ACL reconstruction

Background During anterior cruciate ligament (ACL) reconstruction, different methods of harvesting hamstring tendon may lead to different degrees of injury to the inferior patellar branch of the saphenous nerve (IPBSN). Most of recent studies in the literature suggest that the classic oblique incision (COI) can reduce the incidence of IPBSN injury. We proposed a modified oblique incision (MOI) and compared it with the COI in terms of the resulting levels of injury and sensory loss and the clinical outcome. Methods Patients with ACL injury admitted to our hospital from April 2015 to July 2019 were randomly selected and included in our study. Thirty patients underwent the COI to harvest hamstring tendons, and the other 32 patients underwent the MOI. The pin prick test was performed to detect the sensation loss at 2 weeks, 6 months, and 1 year after the operation. Digital photos of the region of hypoesthesia area were taken, and then, a computer software (Adobe Photoshop CS6, 13.0.1) was used to calculate the area of the hypoesthesia. The length of the incision and knee joint functional score were also recorded. Results At the final follow-up, the incidence of IPBSN injury in COI and MOI were 33.3% and 9.4%, and the areas of paresthesia were 26.4±2.4 cm2 and 9.8±3.4 cm2 respectively. There was no significant difference in the incision length or knee functional score between the two groups. Conclusion The MOI can significantly reduce the risk of injury to the IPBSN, reduce the area of hypoesthesia, and lead to high subjective satisfaction. Therefore, compared with the COI, the MOI is a better method of harvesting hamstring tendons in ACL reconstruction.

A Modified Oblique Incision in Hamstring Tendon Graft Harvesting During ACL Reconstruction

Background: During anterior cruciate ligament(ACL)reconstruction, different methods of harvesting hamstring tendon may lead to different degrees of injury to the inferior patellar branch of the saphenous nerve(IPBSN). Most of recent studies in the literature suggest that the classic oblique incision(COI) can reduce the incidence of IPBSN injury. We proposed a modified oblique incision(MOI) and compared it with the COI in terms of the resulting levels of injury and sensory loss and the clinical outcome.Methods: Patients with ACL injury admitted to our hospital from April 2015 to July 2019 were randomly selected and included in our study. Thirty patients underwent the COI to harvest hamstring tendons, and the other 32 patients underwent the MOI. The pin prick test was performed to detect the sensation loss at 2 weeks, 6 months and 1 year after the operation. Digital photos of the region of hypoesthesia area were taken, and then computer software (Adobe Photoshop CS6, 13.0.1) was used to calculate the area of the hypoesthesia. The length of the incision and knee joint functional score were also recorded. Results: At the final follow-up, the incidence of IPBSN injury in COI and MOI were 33.3% and 9.4%, and the areas of paresthesia were 26.4±2.4 cm2 and 9.8±3.4 cm2 respectively. There was no significant difference in the incision length or knee functional score between the two groups.Conclusion: The MOI can significantly reduce the risk of injury to the IPBSN, reduce the area of hypoesthesia and lead to high subjective satisfaction. Therefore, compared with the COI, the MOI is a better method of harvesting hamstring tendons in ACL reconstruction.

Comparative Results of Percutaneous Calcaneal Osteotomy in Correction of Hindfoot Deformities

Category: Hindfoot Introduction/Purpose: Calcaneal osteotomies are often required in correction of hindfoot deformities. The traditional open techniques as lateral or oblique incision are occasionally associated with wound healing problems and neurovascular injury. Methods: In a prospective study 122 consecutive patients who underwent a calcaneal osteotomy for hindfoot realignment treatment were included. 58 patients were operated using an open incision technique and 64 patients with 66 feet using a percutaneous technique. Clinical and radiological assessments were performed preoperatively, six weeks and one year postoperatively. Results: The AOFAS score and VAS improved in both groups postoperatively. The difference was not significant. The results of the radiological measurements pre- and postoperatively were not significantly different. No pseudarthrosis occurred in both groups. The comparison of both groups showed a significant lesser risk for wound healing problems in percutaneous group (B). The hospitalisation time was significantly shorter in the percutaneous group. Conclusion: Due to the excellent results with the percutaneous calcaneal osteotomy the authors feel encouraged to establish this procedure as a standard technique for calcaneus osteotomy at our clinic.

P957Characteristics of atrial tachycardia after mitral surgey via biatrial trans-septal approach using high density mapping system

Background The biatrial trans-septal approach (BTSa) ameliorates mitral valve (MV) exposure in difficult cases when routine left atriotomy doesnt"t allow it. Main steps are an oblique incision on the right atrium (RA), reaching medially the right pulmonary veins (PV), a septal incision from the fossa ovalis, extended up to reach the first incision, then on the left atrium (LA). Purpose We aim to study the arrhythmic burden in this post-surgical context, focusing on atrial tachycardia (AT), to investigate the complexity of several possible circuits. Methods All patients (>18yo) with previous MV surgery via BTSa for MV repair or replacement, who underwent ablation of AT from January 2017 to September 2019, were enrolled. Patients ablated for persistent or paroxysmal AF, or with AF during the index procedure were excluded. Patients with associated surgery on other valves or congenital defects, coronary, surgical or percutaneous rhythm interventions weren’t excluded. Electroanatomical mapping was created using 2 different high-density mapping system. Substrate and activation map and radio-frequency (RF) ablation (25-50W, Ablation Index target 400) were realized. Cartographies were analysed to evaluate AT re-entry circuit, critical isthmus (CI) location and characterization, atrial vulnerability. Procedural outcomes (AT termination, sinus rhythm (SR) restoration, anti-arrhythmic drugs (AAD) withdrawal), and peri-procedural complications were also evaluated. Results We enrolled 49 patients (median age 57 ± 15), finding a maximum of 5 AT per procedure (2 ± 1). A total of 112 AT were mapped: the majority (72%) were persistent AT, 8,2% common atrial flutter. Cycle length was 314 ± 74 msec, with proximal-distal activation of coronary sinus (78%). A multiple re-entry circuit was observed in 70% of index AT. We identified 152 critical isthmus (maximum 5 per procedure). Only 27,9% of our patients had a single CI; CTI was the most frequent one (n = 37), envolved in 33% of all AT, while BTS scars altogether were envolved in 65% AT. A complete AT circuit was mapped in the RA, the LA and both atria in respectively 49%, 11,5% and 39%AT. The distribution of CIs is shown in figure 1. Biatrial and left AT leads to superior procedure, RF and fluoroscopy duration (p <0,05). SR was restored in 93,4%of patients, requiring a DC shock in 4 cases. Immediate AAD withdrawal was achieved after 41%procedures. No pericardial, oesophageal, vascular or phrenic complication occurred. 4 pace-maker implantations were realized because of 3 interatrial, 2 AV block and a sinus node dysfunction. Conclusions AT occurring after a BTSa have a high prevalence of multiple re-entry circuits with multiple critical isthmus. Ablation in this context is feasible and safe but often requires a left atrial access. Mapping of both atria should be considered to identify critical isthmus and tailored ablation strategy. Abstract Figure 1. Critical Isthmus Distribution

1639 Echocardiographic photorealistic imaging of leiomyomatosis intravascularis

39-years old female patient was admitted to the Department of Cardiac Surgery because of the suspicion of additional mass in the right atrium (RA). She had no symptoms. Two weeks before she underwent surgery because of the tumours of the uterus and the bladder. Moreover, she was treated for papillary thyroid carcinoma 1 year before. D-dimer levels, NTproBNP and markers of cardiac necrosis weren’t elevated. In histopathological examination leiomyomatosis intravascularis was diagnosed. In the transthoracic echocardiography (TTE) we confirmed the presence of additional inhomogeneous, mobile mass in the RA with morphology corresponding to thrombus. Moreover the inferior vena cava (IVC) was also involved. We decided to perform transesophageal echocardiography (TEE). Bicaval view showed that the structure enters through the IVC to the RA and protrude across the tricuspid valve throughout the cardiac cycle. In the photorealistic imaging we could exactly see huge mass that was elongated, mobile, inhomogeneous, had no adhesion with the wall of heart and vein and waved along with the heartbeat (figure 1 A,B). The surgery was performed through median sternotomy. A huge mass with about 30cm length was excised through RA oblique incision, on beating heart with cardiopulmonary bypass (figure 1C). Abstract 1639 Figure. Leiomyomatosis intravascularis

A novel approach to the proximal interphalangeal joint: The volar oblique incision – a retrospective cohort study

Background: The surgical approach to the volar structures in the digits must be designed to provide adequate exposure of tendons, vessels and nerves but also in a way that prevents flexion contracture of the digit as the scar contracts. This is traditionally done using a zigzag ‘Bruner’ incision, first described by Dr Julian M Bruner in 1967. In this paper, we describe an alternative approach, the Volar Oblique incision, and present a single institutional cohort of patients who have undergone procedures beginning with this approach. Methods: A retrospective cohort study was performed on eight cases that involved a Bruner incision and eight similar cases that involved a volar oblique incision. Charts were reviewed for demographic data. Patients were asked to return to clinic postoperatively for scar assessment using the Patient and Observer Scar Assessment Scale (POSAS), where lower scores correspond to more favourable scar characteristics. The average follow-up period was 22 months. While in clinic, standard joint measurements were taken to assess for any proximal interphalangeal joint contracture. Demographics and questionnaire data were analysed using the Mann–Whitney U test for non-parametric data and quantitative joint measurements were analysed using Student’s t-test. Results: There was no difference in flexion contracture between the two groups. The POSAS patient score for scar irregularity was lower in the volar oblique group compared to the Bruner group, but there was no difference in any of the other subcategories, the total patient score, nor the overall patient opinion. The total POSAS observer score was lower in the volar oblique group compared to the Bruner group, with lower scores in the scar thickness, observed relief and observed pliability subcategories as well as the overall observer opinion. Conclusion: The volar oblique incision appears to be satisfactory alternative to the classic Bruner incision in hand surgery that requires volar exposure of the digits. Future studies are needed to assess the validity of these findings on a larger scale. Lay Summary [Formula: see text] There are various types of incisions that surgeons use when they operate on fingers. When choosing an incision, it is important that the incision provides good exposure to the deeper structures but does not form a tight scar that limits movement of the finger (contracture). A commonly used incision for the palmar side of the finger is the zig-zag or ‘Bruner’ incision. Some people, however, find this zig-zag scar unappealing. We started using a single diagonal incision, which we have called the volar oblique, instead of the zig-zag Bruner for access to the middle joint of the finger. We wanted to describe the volar oblique technique and then compare the quality of these two scars and also assess if one limits movement of the finger more than the other. Our research found no differences in finger contracture between groups. We did, however, find that patients reported scar irregularity more favourably in the volar oblique group and that surgeons rated scar thickness, relief (roughness) and pliability of the volar oblique scar higher than that of the zig-zag Bruner scar. This research presents a novel surgical technique and compares its results with respect to scar quality and finger contracture to the more traditional zig-zag Bruner approach.