Comparison of the Effectiveness of Carotid Artery Endarterectomy and Carotid Endarterectomy + Patch Plasty in Preventing Restenosis and Stroke in Carotid Artery Occlusions.

BackgroundCarotid artery stenosis is one of the most important causes of stroke, and atherosclerosis plays a role in one third of all strokes. It has been reported in some studies that the patency rate of carotid endarterectomies performed with patplasty is better than standard surgical treatment. In this retrospective study, we investigated vascular patency rates and strokes due to postoperative restenosis in patients who underwent classical carotid endarterctomy and patch plasty endarterctomy due to carotid artery stenosis.We investigated 126 patients diagnosed with carotid artery occlusion between January 2015 and January 2021. We retrospectively analyzed and compared 44 patients who were operated on using carotid endarterectomy (CAE) with patch technique and 82 patients who underwent only carotid endarterectomy in terms of risk factors, restenosis and stroke. Color Doppler Ultrasonography (CDUS) and Computed Tomographic Angiography (CTA) were used in the diagnosis of carotid artery occlusions and the evaluation of restenosis.Results:The characteristics of the risk factors of the patients were examined and recorded. PTFE graft was used as a patch in patients. There were no significant complications during or after the operation. Restenosis and stroke were investigated at the 10th day, third month, sixth month, and first year after discharge, and mostly by imaging with CDUS. Restenosis was detected in one patient in the study group and in thirteen patients in the control group. Stroke was detected in none of the patients in the study group and in four patients in the control group.Conclusion: In our clinic, patch-based CAE is preferred to primary CAE due to its successful results and very low risk of restenosis. We think that CAE with the patch is a much more effective method in protecting patients from neurological pathologies.

Robotic hernia surgery

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.

Living donor liver transplantation for Budd‒Chiari syndrome with right posterior segment graft and patch plasty using the superficial femoral vein: a case report

Background In living donor liver transplantation (LDLT) for patients with Budd‒Chiari syndrome (BCS), there are several concerns about reconstruction of the inferior vena cava (IVC) and hepatic veins. Herein, we report the case of a patient with BCS who underwent LDLT with right posterior segment graft (RPSG) and patch plasty for reconstruction of the hepatic venous outflow, using the patient’s own superficial femoral vein (SFV). Case presentation A 19-year-old man, who was diagnosed with primary BCS, underwent LDLT. His main hepatic veins were totally obstructed, and membranous stenosis was seen in the IVC. The LDLT donor was his mother; however, liver volumetric analysis showed that only her RPSG was appropriate. In the recipient surgery, 16 cm of the left SFV was harvested and was cut longitudinally and opened. The right hepatic vein (RHV) of the RPSG was anastomosed to the sidewall of the SFV graft. After explantation of native diseased liver was completed, the stenotic and thickened wall of the IVC was widely resected, and a large anastomotic orifice was created. Patch cavoplasty was performed with the RHV‒SFV graft patch. After portal reperfusion started, hepatic venous outflow was satisfactory, and there was no venous graft congestion. Both his postoperative course and his long-term course after discharge were uneventful. Conclusions In LDLT for BCS patients, ingenuity is required for the reconstruction of venous outflow. The SFV patch can be safely harvested from liver transplant recipients and is suitable for venous reconstruction. In addition, RPSG is an alternative type of liver graft for LDLT if a conventional right- or left-lobe graft cannot be used.

Transabdominal Preperitoneal Patch Plasty versus Open Lichtenstein Hernia Repair – A Study

A study to compare the outcomes of laparoscopic transabdominal preperitoneal patch plasty (TAPP) and open Lichtenstein repair in the management of inguinal hernia was carried out at the Department of Surgery, SKIMS Medical College, Bemina, Srinagar, Kashmir, India, from June 2017 to December 2018. Sixty patients with inguinal hernia were enrolled in the study. It was a type of non-randomized prospective cohort study, wherein 30 patients were treated with TAPP and 30 with open Lichtenstein repair. Patients were studied since admission till discharge and followed for 2 years in the outpatient department. Mean operation time in TAPP was higher than the Open Lichtenstein Repair, but the overall complications were higher in the latter. Patients with inguinal hernias who underwent repair by TAPP approach had significantly better post-operative courses than those who undergo open Lichtenstein repair.

Preperitoneal herniation as a complication of tansabdominal preperitoneal patch plasty: a report of two cases

Background Preperitoneal herniation is a rare complication after transabdominal preperitoneal patch plasty (TAPP) and may be caused by inadequate peritoneal closure. We herein report two cases of postoperative small bowel obstruction due to preperitoneal herniation through a disrupted peritoneum. Case presentation Two men in their 70s were admitted to our center because of small bowel obstruction after TAPP. After examinations and unsuccessful conservative treatment, emergency laparoscopic exploration was performed. Preperitoneal herniation through the disrupted peritoneum was found. The herniated small bowel was reduced and the peritoneum was properly reclosed. The patients recovered and were discharged with normal bowel function. Conclusions Inadequate peritoneal closure may cause preperitoneal herniation and lead to postoperative small bowel obstruction and even death. Hernia surgeons can avoid this complication by improving their suture technique and paying attention to the procedure details.

Case Report: Small Bowel Obstruction Owing to Self-Anchoring Barbed Suture Device After TAPP Repair

Groin hernioplasty is the most performed intervention in the adults worldwide, the minimally invasive inguinal hernia repair techniques widely used by surgeons today are transabdominal preperitoneal patch plasty (TAPP) and total extraperitoneal patch plasty (TEP). We report a 62-year-old man with bowel obstruction caused by the use of self-anchoring barbed suture to close the peritoneum 3 days after TAPP. Surgeons using the barbed suture should be alert to this possibility when encountering this complication of intestinal obstruction, so as to avoid more serious consequences.

SURGERY OF TETRALOGY OF FALLOT-15 YEAR EXPERIENCE AT AFIC-NIHD RAWALPINDI

Objective: To compare trans-atrial/Trans-pulmonary and trans-annular/trans-ventricular techniques of surgical correction of tetralogy of fallot. Study Design: Descriptive cross sectional study. Place and Duration of Study: AFIC-NIHD Rawalpindi, from Jan 2005 to Jan 2020. Methodology: Pre-op variables included age, gender, weight, SaO2 and any previous operation (like Modified Blalock Taussig Shunt.) Operative variables were any previous Blalock Taussig Shunts and if present, then their takedown, Cardiopulmonary Bypass Time, Aortic Clamp Time, any Right Ventricle - Pulmonary Artery conduit, Main Pulmonary Artery patch-plasty, Left Pulmonary Artery/ Right Pulmonary Artery patch-plasty, dosage of inotropes and pacing started during weaning off CPB. Post-op variables were mechanical ventilation time (hrs), ventilation time >72 hrs, dosage and duration of inotropes, pacing >24 hrs, renal complications, neurological complications, sepsis, low cardiac output, re-ventilation, tachyarrythmias, any re-opening surgery, mean intensive care unit stay (hrs), overall hospital stay (days) and overall all-cause mortality. Results: A total of 1271 TOF patients were operated. In (38.6%) cases Trans-atrial / Trans-pulmonary approach was used while in 780 (61.3%) correction was done by TAP/TV technique. In both techniques, male patients were 365 (66.4%) vs. 73 (64.1%) females. Mean age was 5 ± 2.3 vs. 4 ± 2.5 years, MPA patch-plasty was 190 ± 5 (38.6%) vs. 780 ± 8 (100%) (p-0.058), RPA/LPA Patch Plasty was 25 ± 6 (5%) vs. 180 ± 10 (23%) (p- 0.025), In ICU, Ventilation hours was 25 ± 8 and 30 ± 12, Ventilation >72 Hrs was 15 (3%) vs. 65 (8.3%) (p-0.015), Inotrope duration >72 Hours was 90 (18.3%) vs. 400 (51.2%) (p-0.338), pacing >24 hours was 30 (6.1%) vs. 150 (19.2%) (p-0.0001), renal complications were 10 (2.3%) vs. 35 (4.4%) (p- 0.285), Neurological complications were 7 (1.4%) vs. 15 (1.9%) (p0.553), Sepsis was 11 (2.2%) vs. 47 (6%) (p-0.33), Low cardiac output was 15 (3%) vs. 66 (8.4%) (p- 1.000), re-ventilation was 10 (2%) vs. 110 (14%) (p- 0.41), Tachy-arrhythmia was 25 (5%) vs. 150 (19.2%) (p- 0.11), re-openings were 19 (3.8%) vs. 65 (8.3%) (p- 0.0003), ICU stay (Hours) was 87 ± 8 vs. 108 ± 10, Mortality was 35 (7.1%) vs. 75 (9.6%) (p-0.094), Mean hospital stay (Days) was 12.2 ± 2.5 vs. 15.8 ± 4.9. Conclusion: Fifteen years’ experience of Tetralogy of fallot corrections at AFIC-NIHD indicates that Trans-atrial / Trans-pulmonary approach is more beneficial to patients due to high survival rate, less morbidity, less hospital stay and an early discharge. This ultimately translates into less financial burden on the patients, hospital, society and the country at large.

Bilayer Mesh Repair for Inguinal Hernia- The Open Alternative to Laparoscopic Repairs

Introduction: In 1999, Gilbert described the technique of using a bilayer mesh device, Prolene Hernia System (PHS) for tension free repairs of inguinal hernias through an open anterior approach. This provides an anterior, posterior and plug repair, and hence successfully covers the myopectineal orifice, the lack of which is a glaring drawback for the Lichtensteins repair. This also confers the same benefit provided by the laparoscopic hernia repairs which uses the preperitoneal space to cover this same region that is, Transabdominal Preperitoneal Patch Plasty (TAPP) and Total Extraperitoneal patch Plasty (TEP). Aim: To observe the overall outcome of using the open bi-layered dual mesh in a population of Odisha, attending a tertiary care hospital. Materials and Methods: All patients admitted with inguinal hernias in the Department of General Surgery, Pradyumna Bal Memorial Hospital, KIMS, Odisha, India were included in the study. They all underwent the PHS bilayer mesh repair. The relevant patient specifics like, preoperative clinical findings and intra and postoperative results were noted in a master chart. Patients were followed-up for one year, and further long-term complications were noted, if any. Results: There were a total of 40 patients. The mean duration for the procedure was 61 minutes (SD-22.8) and there was no inadvertent injury. The patients were encouraged to resume all physical activities from the first postoperative day. All the patients had an uneventful recovery, with a mean hospital stay of four days. Four patients presented with seroma after one week of surgery, while 22 patients had cord oedema. Both subsided spontaneously within three weeks, without further intervention. No recurrence was noted in any of the patients. Conclusion: The PHS bilayer dual mesh repair is ideally suited for population in a low resource setting. It ensures coverage of the entire vulnerable area of groin along with a considerably shorter duration of operation, minimal risk of intraoperative injury.

Cardiac recovery following left ventricular assist device therapy: experience of complete device explantation including ventricular patch plasty

OBJECTIVES Myocardial recovery is a rare phenomenon in left ventricular assist device (LVAD) therapy. Surgical LVAD removal is associated with the risk of cardiac failure, and the individual evaluation of sufficient myocardial recovery is crucial. Thus, complete device explantation is not consistently performed to minimize perioperative risk. However, the remaining ventricular assist device components bear significant risks of infection or thrombosis. Therefore, we developed this study to evaluate a complete LVAD explantation protocol. METHODS All patients in our institution who had an LVAD explanted were enrolled in the study. Explant surgery involved removal of the driveline, pump housing, sewing ring and outflow graft. The ventricular wall was reconstructed by double patch plasty. Our analysis focused on surgical and postoperative outcome parameters, including all-cause mortality and major adverse cardiac and cerebrovascular events. RESULTS A total of 12 patients (HVAD, n = 5; HeartMate II, n = 3; HeartMate 3, n = 4) had myocardial recovery and qualified for our LVAD explantation study protocol [median age: 40 years, interquartile range (IQR) 33–52 years; 50% men]. Primary heart failure aetiology: myocarditis (n = 5), dilated cardiomyopathy (n = 4), toxic cardiomyopathy (n = 2) and valvular heart failure (n = 1). The median average duration on LVAD was 10 months (25–75%: IQR 8.5–30 months). The median left ventricular ejection fraction was 15% (IQR 13–18%) at LVAD implantation and 50% (IQR 45–50%) before LVAD explantation (P = 0.0025).The 30-day survival was 100%. The 1-year survival was 91.7%. All patients were discharged after a median 13 days (IQR 10–18 days) postoperatively. No patient had major adverse cardiac and cerebrovascular events. The New York Heart Association functional class remained consistent during the follow-up period (median New York Heart Association functional class: II, IQR II–II class) including preservation of ventricular function. CONCLUSIONS Complete LVAD explantation with ventricular patch plasty is feasible and has consistent long-term results.

Ascending aorta replacement in patients with coronary ostia localized above the sinotubular junction

OBJECTIVES The study objective was to describe the technique and outcomes of original coronary ostial slide plasty in patients with anomalous coronary artery origin (ACAO) localized in the aneurysmal ascending aorta (AA) being replaced because of its isolated pathology and otherwise non-pathological aortic root. METHODS A total of 23 patients (median age 52 years) with the ascending phenotype of proximal aorta aneurysm and ACAO of at least 1 coronary artery localized in the AA being replaced underwent ostial slide plasty to transpose the ACAO to the respective sinus of Valsalva and, consequently, to allow an AA replacement with placement of the proximal anastomosis at the level of the sinotubular junction (STJ). In 15 patients, the aortic valve was bicuspid, and all but 3 patients presented with a relevant valve defect. In addition to remodelling the STJs (all patients), valve-sparing repair or replacement was performed in 12 and 8 patients, respectively. RESULTS No patient died during the entire follow-up (median 72, range 3–183 months). One patient required replacement of a recurrently insufficient valve that was repaired primarily using cusp patch plasty, but there were no further cardiac reoperations nor any re-interventions on the proximal aorta, aortic valve and/or coronary artery ostia. Two patients received peripheral coronary stents (8 and 7 years after surgery, respectively) due to coronary heart disease. CONCLUSIONS Transposition of the ACAO from the replaced AA into the normal sinus of Valsalva using the ostial slide plasty offers a simple and safe surgical option enabling a recreation of a durable STJ at the level of the anastomosis between the root and the aortic graft.