Search

INTRODUCTION: As surgical technologies grow, so too do demands on surgical trainees to master increasing numbers of skill sets. With the rise of endovascular surgery, trainees have fewer opportunities to practice open vascular techniques in the operating room. Simulation can bridge this gap. However, existing published open vascular simulation curricula are basic or based on expensive models. METHODS: We iteratively developed an open vascular skills curriculum for second-year surgery residents comprising six 2-hour sessions. We refined the curriculum based on feedback from learners and faculty. The curriculum required skilled facilitators, vascular instruments, and tissue models. We evaluated the latest iteration with a survey and by assessing participants technical skills using the Objective Structured Assessment of Technical Skills (OSATS) form. RESULTS: Over the past 10 years, 101 residents have participated in the curriculum. Nine of 13 residents who participated in the latest curricular iteration completed the survey. All respondents rated the sessions as excellent and strongly agreed that they had improved their abilities to perform anastomoses with tissue and prosthetic. Facilitators completed 18 OSATS forms for residents in the fifth and sixth sessions of the latest iteration. Residents scored well overall, with a median 26.5 (interquartile range: 24-29) out of a possible score of 35, with highest scores on knowledge of instruments. DISCUSSION: This simulation-based curriculum facilitates open vascular surgical skill acquisition among surgery residents. The curriculum allows residents to acquire critical vascular skills that are challenging to learn in an increasingly demanding operative setting.

Background Gentian violet ink is used as a skin marker in various surgical procedures, including neurosurgery. The dye is also used to visualize the edges of blood vessels during bypass surgery. However, gentian violet ink carries the risks of carcinogenicity and venous injury, which causes microvascular thrombosis. In this study, we compare the gentian violet–free dye C.I. Basic Violet 4 (BV4) and gentian violet. The usefulness, in terms of color, and formation of microvascular thrombosis in anastomosis were compared. Methods We used the gentian violet–free dye in 20 cases involving 3 vascular anastomoses. The bone cutting lines on the bone surface, superior temporal artery, and middle cerebral artery were drawn using BV4 and gentian violet ink. Results The colors of BV4 and gentian violet ink were similar. No thrombus formation was observed at the vascular anastomosis when using BV4. Conclusion BV4 can be used similarly to gentian violet ink. No adverse effects such as thrombus formation in microvascular anastomosis were experienced when BV4 was used. [ABSTRACT FROM AUTHOR]

The Symani surgical system undergoes scrutiny in this study as part of a series of preclinical investigations. Previous studies compared the precision of robotic-assisted anastomoses with manual techniques. This study aimed to evaluate the critical, histological, and gross parameters at the site of anastomosis and at distant sites in a rat model to provide insights into the safety and efficacy of robotic-assisted microsurgery to enhance its potential for clinical adoption. Experienced microsurgeons performed arterial and venous anastomoses in 16 Wistar rats, randomized into four treatment groups: robotic artery, robotic vein, manual artery, and manual vein. Various parameters were evaluated at two time points (T0 and T30) on the day of the procedure and at Day 28 (T28d). In the second phase of the study, the animals underwent necropsy, histopathologic analysis, micro-CT scans, and angiography imaging of the anastomosis sites, major organs, and distant target organs by a blinded assessor. Patency rates were 100% at T0 and T30 for all anastomoses and stayed at 100% on T28d for the robotic subgroups; however, it decreased to 87.5% for manual arterial anastomoses owing to a case of obstructive thrombus. No evidence of clot migration was observed. Blood flow parameters and procedure times did not differ significantly. The blinded semiquantitative histological analysis revealed no significant disparities between the robotic and manual anastomoses across various pathological indicators. No gross abnormalities were detected in musculoskeletal examinations. This preclinical study demonstrated the safety of the Symani surgical system. Results suggest equivalence between robotic and manual techniques regarding thrombus formation at the anastomotic site and distal organs. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to compare the clinical efficacy and quality of life of B-IIB (Billroth-II with Braun anastomosis) and B-II (Billroth-II anastomosis) in the alimentary tract reconstruction postoperative totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. Methods: From February 2016 to January 2022, 158 patients underwent totally laparoscopic distal gastrectomy and D2 lymphadenectomy in Northern Jiangsu People's Hospital, with Billroth-II with Braun anastomosis for 93 patients and Billroth-II anastomosis for 65 patients. The patients' data were collected prospectively and reviewed retrospectively. Results: In this study, the post-op hospital stay of B-IIB group were shorter than B-II group (12.70 ± 3.08 days in the B-IIB group versus 14.12 ± 4.90 days in the B-II group, p < 0.05) and the first post-op flatus time of the B-IIB group were shorter than B-II group (3.49 ± 1.02 days versus 4.08 ± 1.85 days, p < 0.05). Two groups did differ significantly in hemoglobin on postoperative 3 months, albumin at 3 months after operation, and serum sodium on postoperative 3 days and 3 months (p < 0.05), and the B-IIB had an advantage; the complications incidence (Clavien-Dindo grade II or even a higher grade) of the B-IIB group and B-II group were 10.75% and 29.23%, respectively. There being a statistical difference between the two groups. The B-IIB group and the B-II group both had different degrees of weight loss at 3 months after operation compared with preoperative weight. The weight of B-IIB group was 4.04 ± 1.33 kg, which was less than B-II group (8.08 ± 1.47 kg). The difference was statistically significant (p < 0.05). According to the PGSAS (Postgastrectomy Syndrome Assessment Scale), the score of the B-IIB group is lower than that of the B-II group for esophageal reflux gastritis, dyspepsia, and dumping syndrome group (1.84 ± 0.92 VS 2.15 ± 0.85, P = 0.031; 1.86 ± 1.10 VS 2.22 ± 0.91, P = 0.034; 1.98 ± 1.06 VS 2.32 ± 0.94, P = 0.037, respectively). Conclusion: Totally laparoscopic distal gastrectomy with Billroth-II Braun reconstruction is a safe and technically feasible method for gastric cancer patients, which can reduce the incidence of postoperative reflux esophagitis and dumping syndrome. Compared with Billroth-II reconstruction, it has advantages in maintaining postoperative nutritional status and electrolyte balance and improving quality of life. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion Colorectal cancer is the third most common cancer and the second highest cause of cancer mortality in Australia. Despite advances in colorectal surgery, anastomotic leak still occurs in low‐risk patients and is a substantial cause of morbidity and mortality. Many operative strategies are used to assess anastomotic integrity such as an air leak test or intraoperative flexible sigmoidoscopy, however an objective anastomotic checklist is yet to be developed and studied. This study aims to develop a photodocumentary anastomotic specific checklist and determine its feasibility for implementation.Patients undergoing left sided colorectal resections with primary anastomosis without a de‐functioning ileostomy were prospectively included between May 2021 and December 2022. A photographic checklist assessing anastomotic perfusion, integrity via either air test or endoscopic image, evidence of complete operative doughnut specimens and the assessment of tension was implemented. The feasibility of an anastomotic checklist was externally validated by four independent colorectal surgeons from Australia, New Zealand and United States of America.The anastomotic checklist was completed in 44 patients. Mean age was 62 years, with 43% male and mean BMI 28. Operations included high anterior resection (45%), low anterior resection (18%), ultra‐low anterior resection (20%), reversal of Hartmann's (11%). Median length of stay was 4 days. Complications post operatively were documented in six patients with anastomotic leak in 2% and wound infection in 6.8%. Intraclass correlation coefficients were poor amongst all reviewers with air leak and tension having no inter‐reviewer correlation.The introduction of an anastomotic checklist was a feasible tool to systematically assess and document anastomotic integrity. Unfortunately, with the small sample size there was significant discrepancy in inter‐observer variability, and this led to poor correlation regarding which patients were typically high risk requiring a temporary ileostomy. Larger studies on the implementation of an anastomotic checklist will be needed to evaluate if it is an inherently feasible approach and if there is an effect on anastomotic leak. [ABSTRACT FROM AUTHOR]

Advancements in laparoscopic technology have popularized laparoscopic total gastrectomy over traditional open surgery, yet postoperative complications like anastomotic leakage and stenosis persist, particularly in esophagojejunostomy. To address this, since 2017, the authors have introduced the “Pant-Shaped” esophagojejunostomy as an improvement over the classic Roux-en-Y method, especially beneficial for patients with small intestinal diameters or those with gastric body cancer or Siewert III. To assess the viability and safety of employing ‘Pant-Shaped’ anastomosis following laparoscopic-assisted total gastrectomy. A method of descriptive case study was used. In our department of the First Affiliated Hospital of Wannan Medical College, records of 210 patients who underwent laparoscopic-assisted total gastrectomy for gastric body cancer or adenocarcinoma at the junction of esophagus and jejunum with “Pant-Shaped” anastomosis between January 2017 and December 2022 were examined. Clinicopathological features and postoperative conditions were also examined and assessed. The mean age of the 164 male and 46 female research participants was 69.2 ± 8.3 years. There was a mean estimated blood loss of 63.4 ± 29.7 ml, an anastomosis time of 25.9 ± 3.0 minutes, an operation time of 208.2 ± 40.4 minutes, and a postoperative hospital stay of 12.2 ± 8.0 days. Nine patients (4.3%) experienced postoperative problems (Clavien-Dindo > grade II), including two episodes of anastomotic leakage that were resolved with irrigation and drainage, anti-infection therapy, and nutritional assistance. After an unforeseen reoperation, two cases of duodenal stump leaking were resolved. Anastamotic hemorrhage was treated with hemostasis and blood transfusion, and the patient made a full recovery. Due to a Peterson’s hernia, one patient required emergent open surgery. three months subsequent to LATG. The “Pant-Shaped” anastomosis method after laparoscopic-assisted total gastrectomy is simple, easy to promote, and has fewer complications. It is a safe and feasible modified method for esophagojejunostomy, especially suitable for patients with poor intestinal dilation and contraction ability and small jejunal diameter. [ABSTRACT FROM AUTHOR]

OBJECTIVES The objective of this study was to enhance the efficiency of aortic arch replacement through the development of a novel frozen elephant trunk (FET) prosthesis with an endovascular side branch for left subclavian artery (LSA) connection. After successful pre-clinical testing, the feasibility and safety of implementing this innovative prosthesis in human subjects were investigated. METHODS Between September 2020 and September 2021, 4 patients (mean age 67) with conditions such as penetrating ulcer, non A–non B aortic dissection and chronic arch aneurysm underwent surgery utilizing the customized device. Surgeries were performed under high moderate hypothermia (27°C), employing bilateral selective antegrade cerebral perfusion (SACP) and distal aortic perfusion. Anastomosis of the FET prosthesis with the aortic arch occurred in zone 1, followed by separate reimplantation of the left common carotid artery and the brachiocephalic artery. RESULTS All patients were discharged in good clinical condition. The mean aortic cross-clamp, antegrade selective cerebral perfusion and distal aortic perfusion times were 111, 71 and 31 min, respectively. Endovascular extension of the side branch for the LSA was required in all cases to prevent endoleak formation. One patient received a stent graft extension at the end of the operation, while 2 others underwent the procedure during their hospital stay. One patient was diagnosed with an endoleak at the first follow-up after 3 months, and endoleak sealing was achieved via the brachial artery with an extension stent graft. CONCLUSIONS Preliminary clinical outcomes suggest that the newly designed FET prosthesis shows promise in simplifying total arch replacement. These initial findings provide a foundation for planned clinical studies to further assess the effectiveness of this modified surgical hybrid graft, with particular attention to the length and diameter of the LSA sidearm. [ABSTRACT FROM AUTHOR]

Aim: Surgeon personality is a factor influencing rectal anastomotic decision‐making. However, it is unclear how or why this may be the case, or what aspects of personality are involved. The aim of this study was to investigate the views of colorectal surgeons on how their individual personality may influence variation in anastomotic decision‐making. Method: Purposive sampling was used to invite certified UK‐based colorectal surgeons to participate, with individual interviews used for data collection. Participants were recruited until ongoing data review indicated no new codes were generated (i.e. data sufficiency). Data were analysed thematically following Braun and Clarke's six‐step framework. Results: Seventeen colorectal surgeons (eight female, nine male) participated. Two key themes relating to personality and decision‐making were identified: (1) surgeon development and training and (2) patient–surgeon interactions, each with relevant subthemes. Surgeons described how their personality may influence patients' postoperative outcomes (e.g. decision‐making, team working and communication) and potential mechanisms for how their personality may influence operative risk‐taking. Following anastomotic leakage, surgeons described a disproportionate sense of guilt and responsibility. There appears to be a significant transition in responsibility from trainee to newly appointed consultant, which may be part of the 'hidden curriculum' of surgical training. Conclusion: Colorectal surgeons have described their perceptions of how personality traits may impact variation in decision‐making and patient outcomes for the first time. Early career surgeons felt ill‐prepared for the level of guilt experienced when managing complications. Surgeons appear open to personality assessment if this was through an educational lens, with the aim of improving decision‐making following complications and overall performance. [ABSTRACT FROM AUTHOR]

Introduction: There is a controversy in minimally invasive colorectal procedures regarding choosing optimal technique between intra-corporeal (ICA) and extra-corporeal anastomosis (ECA). Previous studies recognize the short-term benefits in right hemicolectomy with intra-corporeal approach; however, ICA can result in increased operative difficulty. The aim of this study is to understand attitudes towards teaching ICA in colorectal procedures and how this varies between subspeciality training. Methods: Active members of General Surgeons Australia were contacted through email to participate in a voluntary, unincentivized survey. Demographic details were collected and participants were asked to rate agreement for simulation-based training for increasing adoption of ICA through a Likert scale and when preferences for teaching ICA. Descriptive statistics were completed to describe frequencies and ordinal regression was completed to determine factors for Likert scale question. Results: There were 43 respondents and most participants recognized that ECA was easier to teach trainees and should be taught first. 53.5% of respondents recognized that simulation-based training would assist the adoption of ICA. Surgeons who routinely close bowel or enteric defects intra-corporeally are 354% more likely to show an interest in simulation-based training for adopting ICA, however, surgeons who are not involved in teaching trainees did not show an interest in simulation-based training. Conclusion: There is significant agreement that ECA forms the basis to learn ICA and simulation-based training would assist with the uptake of ICA. However, a multimodal approach, including expanding training avenues and providing financial incentives, would be necessary to enhance the adoption of ICA in colorectal surgery. [ABSTRACT FROM AUTHOR]

Aim: To assess the viability of this procedure in laparoscopic radical cystectomy with ileal orthotopic neobladder reconstruction, the objective of this study is to examine the relationship between urinary flow parameters of urethral drag-and-bond anastomosis in the reconstruction of the ileal orthotopic neobladder. Methods: 36 patients with bladder cancer underwent laparoscopic radical cystectomy with ileal orthotopic neobladder reconstruction at Jiangxi provincial people's hospital between June 2016 and January 2021,16 patients underwent intermittent urethral anastomosis, while 20 patients underwent neobladder-urethral drag-and-bond anastomosis. The maximum bladder capacity, residual urine output, maximum urinary flow rate, and outlet morphology of the new bladder neck were all monitored throughout postoperative follow-up regularly. Results: There was no significant difference between the urethral drag-and-bond anastomosis group (group A) and the conventional anastomosis group (group B) at 3 months and 12 months after surgery, and the maximum bladder capacity (3 months, 488.35 ± 51.56 ml vs 481.06 ± 40.61 ml, t = −0.462, P = 0.647; 12 months, 496.35 ± 51.09 ml vs 476.56 ± 56.33 ml, t = −1.103, P = 0.278), residual urine output (3 months, 44.15 ± 24.12 ml vs 38.69 ± 21.82 ml, t = −0.704, P = 0.486;12 months, 49.65 ± 26.95 ml vs 36.75 ± 21.96 ml, t = −1.546, P = 0.131) and maximum urine flow rate (3 months, 12.36 ± 2.63 ml/s vs 13.60 ± 2.82 ml/s, t = 1.361, P = 0.182;12 months, 12.18 ± 3.14 ml/s vs 11.13 ± 3.01 ml/s, t = −1.004, P = 0.322) of the two groups were not significant (P > 0.05). The new bladder outlet morphology was not distorted in group A patients, the continuity was good, and there were fewer associated complications. Conclusions: There was no significant difference in postoperative urodynamic parameters between the urethral drag-and-bond anastomosis group and the conventional anastomosis group, and the postoperative new bladder outlet was in good shape, with clinical significance. [ABSTRACT FROM AUTHOR]

Although circular staplers offer technical advancements over traditional hand-sewn techniques, their use remains challenging for unskilled users, necessitating substantial time and experience for mastery. In particular, it is challenging to apply a consistent pressure of an appropriate magnitude. We developed an automated circular anastomosis device using artificial intelligence (AI) to solve this problem. Automation through AI reduces experiential factors during the anastomosis process. We defined damage occurring during the anastomosis process, noting that a greater depth of damage indicated a more severe injury. For automated anastomosis, data at a tissue strain of 40% were used for the AI model, as this strain level showed optimal performance based on the accuracy and cost matrix. We compared the outcomes of automated anastomosis using a trained AI with those of unskilled users. The results were validated using the Shapiro–Wilk test and t tests. Compression damage was verified on collagen sheets. The AI-driven automatic compression system resulted in less damage compared to unskilled users. In particular, a more significant difference in damage was observed in poor-condition collagen than in good-condition collagen. Damage to the collagen under poor conditions was 54.8% when handled by unskilled users, while the AI-driven automatic compression system resulted in 38.9% damage. This study confirmed that novices' use of AI for automated anastomosis reduces the risk of damage, especially for tissues in poor condition. [ABSTRACT FROM AUTHOR]

Background: Although functional end-to-end anastomosis (FEEA) using a stapler in the colorectal field has been recognised worldwide, the technique varies by surgeon, and the safety of anastomosis using different techniques is unknown. Methods: This multicentre prospective observational cohort study was conducted by the KYCC Study Group in Yokohama, Japan, and included patients who underwent colonic resection at seven centres between April 2020 and March 2022. This study compared the incidence of surgery-related abdominal complications (SAC: anastomotic leakage [AL], anastomotic bleeding, intra-abdominal abscess, enteritis, ileus, surgical site infection, and other abdominal complications) between two different methods of FEEA (one-step [OS] method: simultaneous anastomosis and bowel resection; two-step [TS] method: anastomosis after bowel resection). Complications of Clavien–Dindo classification grade 2 or higher were assessed. Results: Among 293 eligible cases, the OS and TS methods were used in 194 (66.2%) and 99 (33.8%) patients, respectively. The baseline characteristics were similar between the groups. The OS method used fewer staplers (three vs. four staplers, p < 0.00001). There were no significant differences in SAC rate between the OS (19.1%) and the TS (16.2%) groups (p = 0.44). The OS group had four cases (2.1%) of AL (two patients; grade 3, two patients; grade 2) while the TS group had one case (1.0%) of grade 2 AL (p = 0.67). Multivariate logistic regression analysis showed that male sex (odds ratio [OR] 3.95; p < 0.00001), an open surgical approach (OR 2.36; p = 0.03), and longer operative duration (OR,2.79; p = 0.002) were independent predictors of complications, whereas the OS method was not an independent predictor (OR 1.17; p = 0.66). Conclusions: The OS and the TS technique for stapled colonic anastomosis in a FEEA had a similar postoperative complication rate. Trial registration number: UMIN000039902 (registration date 23 March 2020). [ABSTRACT FROM AUTHOR]

Purpose: Routine use of abdominal drain or prolonged antibiotic prophylaxis is no longer part of current clinical practice in colorectal surgery. Nevertheless, in patients undergoing laparoscopic right hemicolectomy with intracorporeal anastomosis (ICA), it may reduce perioperative abdominal contamination. Furthermore, in cancer patients, prolonged surgery with extensive dissection such as central vascular ligation and complete mesocolon excision with D3 lymphadenectomy (altogether radical right colectomy RRC) is called responsible for affecting postoperative ileus. The aim was to evaluate postoperative resumption of gastrointestinal functions in patients undergoing right hemicolectomy for cancer with ICA and standard D2 dissection or RRC, with or without abdominal drain and prolonged antibiotic prophylaxis. Methods: Monocentric factorial parallel arm randomized pilot trial including all consecutive patients undergoing laparoscopic right hemicolectomy and ICA for cancer, in 20 months. Patients were randomized on a 1:1:1 ratio to receive abdominal drain, prolonged antibiotic prophylaxis or neither (I level), and 1:1 to receive RRC or D2 colectomy (II level). Patients were not blinded. The primary aim was the resumption of gastrointestinal functions (time to first gas and stool, time to tolerated fluids and food). Secondary aims were length of stay and complications' rate. ClinicalTrials.gov no. NCT04977882. Results: Fifty-seven patients were screened; according to sample size, 36 were randomized, 12 for each arm for postoperative management, and 18 for each arm according to surgical techniques. A difference in time to solid diet favored the group without drain or antibiotic independently from standard or RRC. Furthermore, when patients were divided with respect to surgical technique and into matched cohorts, no differences were seen for primary and secondary outcomes. Conclusion: Abdominal drainage and prolonged antibiotic prophylaxis in patients undergoing right hemicolectomy for cancer with ICA seem to negatively affect the resumption of a solid diet after laparoscopic right hemicolectomy with ICA for cancer. RRC does not seem to influence gastrointestinal function recovery. [ABSTRACT FROM AUTHOR]

(1) Background: In recent years, there has been a change in practice for diverting stomas in rectal cancer surgery, shifting from routine diverting stomas to a more selective approach. Studies suggest that the benefits of temporary ileostomies do not live up to their risks, such as high-output stomas, stoma dysfunction, and reoperation. (2) Methods: All rectal cancer patients treated with a robotic resection in a single tertiary colorectal centre in the UK from 2013 to 2021 were analysed. In 2015, our unit made a shift to a more selective approach to temporary diverting ileostomies. The cohort was divided into a routine diversion group treated before 2015 and a selective diversion group treated after 2015. Both groups were analysed and compared for short-term outcomes and morbidities. (3) Results: In group A, 63/70 patients (90%) had a diverting stoma compared to 98/135 patients (72.6%) in group B (p = 0.004). There were no significant differences between the groups in anastomotic leakages (11.8% vs. 17.8%, p = 0.312) or other complications (p = 0.117). There were also no significant differences in readmission (3.8% vs. 2.6%, p = 0.312) or reoperation (3.8% vs. 2.6%, p = 1.000) after stoma closure. After 1 year, 71.6% and 71.9% (p = 1.000) of patients were stoma-free. One major reason for the delay in stoma reversal was the COVID-19 pandemic, which only occurred in group B (0% vs. 22%, p = 0.054). (4) Conclusions: A more selective approach to diverting stomas for robotic rectal cancer patients does not lead to more complications or leaks and can be considered in the treatment of rectal cancer tumours. [ABSTRACT FROM AUTHOR]

IntroductionRigid proctosigmoidoscopy (RP) and flexible sigmoidoscopy (FS) are two modalities commonly used for intraoperative evaluation of colorectal anastomoses. This study seeks to determine whether there is an association between the endoscopic modality used to evaluate colorectal anastomoses and the rate of anastomotic leak (AL), organ space infection, and overall infectious complication.MethodsThe 2012-2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing colorectal anastomoses. Anastomotic evaluation method (RP versus FS) was identified by Current Procedural Terminologycoding and used for group classification. Outcomes measured included AL, organ space infections, and overall infection. Multivariable logistic regression analysis for predicting AL was performed.ResultsWe identified 7100 patients who underwent a colorectal anastomosis with intraoperative endoscopic evaluation. RP was utilized in 3397 (47.8%) and FS in 3703 (52.2%) patients. RP was used more commonly in diverticulitis (44.5% versus 36.2%, P

Purpose: The aim of the study is to classify the superficial veins of the anterior region of the forearm (regio antebrachii anterior) in healthy individuals aged 18 to 68 years, and to gather data on the anastomotic patterns and course of these veins. Materials and Methods: In this study, conducted at Firat University Hospital, a total of 400 arms from individuals aged 18 to 68 years were examined using the Accuvein AV300 vein imaging device. Among them, 100 were male and 100 were female. The superficial veins including v. cephalica, v. basilica, and v. mediana antebrachii originating from the palmar manus were classified based on their course and anastomotic patterns in the regio antebrachii anterior. Results: In the study, the distribution of superficial vein types in the regio antebrachii anterior was compared based on gender and symmetry between the right and left arms. The comparison revealed statistically significant differences between the right and left arms in the classification of v. cephalica and v. basilica veins, while no significant difference was found for v. mediana antebrachii. Conclusion: As a result of the data obtained, the study conducted; We anticipate that it will provide information about the course and anastomoses of the veins in this region, which is difficult to dissect.

Leakage of intestinal anastomoses remains an issue in view of the increasing number of patients who need reconstructive interventions in different parts of the gastrointestinal tract. Researchers around the world are actively looking for methods of strengthening intestinal anastomoses. The literature presents various approaches to sealing intestinal anastomoses in experimental animals using allografts, biological sealants, polymer film materials, etc. This article classifies and analyzes innovative methods of strengthening intestinal anastomoses to prevent their leakage. We also describe a concept of developing polymer membranes for interventions on hollow organs and our experience in this field of work and making of medical devices at the premises of a university research laboratory.

Aim of the study was to evaluate the features of the anatomy of the deep vein of the femur according to CT-phlebography data. Material and methods. The data of CT-phlebography of 100 limbs of 50 patients (27 women, 23 men, mean age 39 years, age range 28–46 years) obtained in 2021–2023 were used as the basis of the work. The study was performed according to the original technique (patent of the Russian Federation N 2799023) on a 128-slice multispiral computed tomography scanner, with slice thickness of 0.5 mm, intravenous injection of contrast agent. The diameter of the femoral deep vein at different levels, the presence of additional trunks and its anastomoses with other segments of deep and superficial veins were evaluated. Results. True doubling of the femoral deep vein occurs with a frequency of 6 %, anastomoses of the femoral deep vein with the femoral-pubic segment of deep veins in 62 % cases. Variant anatomy with direct transition of the femoral or popliteal vein into the femoral deep vein occurs in 13 % of observations. Conclusions. The data on variant anatomy of the deep vein and its tributaries may be of practical importance when it is necessary to diagnose or choose the technique of surgical intervention in patients with venous diseases of the lower extremities.

ABSTRACT: Background: The introduction of robotic assistance in surgical practice has led to advancements such as the MUSA-2 robotic system that was designed for microsurgical procedures. Advantages of this system include tremor filtration and motion scaling. Initial studies showed promising results in skill acquisition for robot-assisted microsurgery. This study evaluated the learning curve for microsurgical anastomosis with and without robotic assistance among surgeons of varying experience levels. Methods: Fifteen surgeons were divided into 3 groups (novice, intermediate, and expert) based on their microsurgical experience. They performed 10 anastomoses by hand and 10 with robotic assistance on synthetic polyvinyl alcohol vessels (diameter of 2 mm) in a laboratory setting. Participants were timed and mistakes such as backwall and leakage were assessed and recorded. Demographic information was collected. Results: Statistical differences were found in manual anastomosis times between the intermediate and novice groups compared to the experts (p < 0.01). However, no statistical difference was found in the mean time between groups for the robot-assisted anastomoses. Novice doctors had the steepest learning curve for hand-sewn anastomosis. Experts had the fastest completion time at the end of the 10th robotic session, finishing at 14 min, compared to 33 min at the 2nd session. All groups reduced their mean time in half through their 10 robotic sessions. Conclusion: This study indicated similarities in the learning curves for robot-assisted anastomosis among surgeons with varied experience levels. Experts excelled technically in manual anastomoses, but robot-assistance enabled novice and intermediate surgeons to perform comparably to the experts. Robotic assistance may aid more novice learners in performing microsurgical anastomosis safely at earlier points in their education.

Abstract Background The fundamental prerequisite for prognostically favorable postoperative results of peripheral nerve repair is stable neurorrhaphy without interruption and gap formation. Methods This study evaluates 60 neurorrhaphies on femoral chicken nerves in terms of the procedure and the biomechanical properties. Sutured neurorrhaphies (n = 15) served as control and three sutureless adhesive-based nerve repair techniques: Fibrin glue (n = 15), Histoacryl glue (n = 15), and the novel polyurethane adhesive VIVO (n = 15). Tensile and elongation tests of neurorrhaphies were performed on a tensile testing machine at a displacement rate of 20 mm/min until failure. The maximum tensile force and elongation were recorded. Results All adhesive-based neurorrhaphies were significant faster in preparation compared to sutured anastomoses (p

The effectiveness of closed drainage tube insertion after low anterior resection has been controversial. We believe that drain tube displacement, which occurs up to 35% in real clinical practice, reduces the effectiveness of the drain tube. We report in this video a simple way to secure the drain tube in the pelvic cavity after low anterior resection and introduce a case that used the drain fixation method and treated anastomotic leakage without interventional procedure.

Abstract Objectives Redo surgery for pelvic fracture urethral distraction defects (PFUDDs) is still a challenge. the long urethral defect makes it difficult while the high tension increase the recurrence rate. Although certain ancillary maneuvers can relieve tension, there is no consensus or guidelines for the prediction/planning of the selection. In this study, we present our experience with developing an intraoperative guidance system to achieve tension-free urethral anastomosis. Patients and methods A total of 91 recurrent PFUDD patients managed at our center between 2020 and 2022 were retrospectively analyzed. The patients underwent scar removing and urethral anastomosis. For the long defect and high-tension cases, 6 kinds of tension-relieving maneuvers were used respectively during the process of urethral anastomosis. Preoperative assessment of the urethrogram was done before surgery, while biaxial (vertical and horizontal) defect measurements were performed intraoperatively. The patients were followed-up for 12 months (8.9 ± 4.2), furthermore, recurrence and complications were analyzed. Results The overall success rate was 86.81%. The mean defect in urethrogram was 2.9 ± 1.1 cm. 27 simple anastomosis was performed when the vertical plus horizontal defect was less than 2 cm with 11.11% recurrence. 24 cavernous septum splittings were performed when the horizontal defect was greater than 2 cm with 8.33% recurrence. 21 inferior pubectomies were performed when the horizontal defect was greater than 3 cm with 19.05% recurrence. 15 ancillary distal urethra manipulations (fully distal urethral mobilization, urethral suspension and corpus cavernosa folding) were performed when the vertical defect was 3 to 4 cm with 13.33 recurrence. 4 reroutings were performed when the vertical defect was greater than 4 cm with 25.00% recurrence. Conclusions Ancillary maneuvers are effective for reducing tension in redo urethral anastomosis. Measurement of divergent vertical and horizontal urethral defects could guide the selection of ancillary maneuvers. Combined tension-relieving maneuvers is recommended according to the defect direction and length to achieve a tension-free anastomosis.

The development of novel robotic devices specifically designed for open microsurgery leads to increasing applications in reconstructive procedures. While initial studies revealed improved precision and surgical ergonomics upon robotic assistance, surgical time was consistently observed to be increased. This study compares two robotic suturing techniques using the Symani Surgical System and RoboticScope in a preclinical setting, to further leverage the benefits of novel robotic devices in microsurgery. Six experienced microsurgeons performed three microvascular anastomoses with a "steady-thread" suturing technique and a "switch-thread" technique on 1.0-mm-diameter artificial silicone vessels. Time for anastomosis and participant's satisfaction with the techniques and robotic setup were recorded. Anastomosis quality and microsurgical skills were assessed using the Anastomosis Lapse Index and Structured Assessment of Microsurgery Skills. Lastly, technical error messages and thread ruptures were quantified. Knot tying was significantly faster and evaluated significantly better by participants using the steady-thread technique (4.11 ± 0.85 vs. 6.40 ± 1.83 min per anastomosis). Moreover, microsurgical skills were rated significantly better using this technique, while both techniques consistently led to high levels of anastomosis quality (2.61 ± 1.21 vs. 3.0 ± 1.29 errors per anastomosis). In contrast, the switch-thread technique was associated with more technical error messages in total (14 vs. 12) and twice as many unintended thread ruptures per anastomosis (1.0 ± 0.88 vs. 0.5 ± 0.69). This study provides evidence for the enhanced performance of a steady-thread suturing technique, which is suggested to be applied upon robot-assisted microsurgical procedures for optimized efficiency. [ABSTRACT FROM AUTHOR]

Introduction Material and Methods Results Conclusions Twin–twin transfusion syndrome (TTTS) complicates approximately 10%–15% of all monochorionic twin pregnancies. The aim of this review was to evaluate the placental architectural characteristics within TTTS twins following laser and elucidate their impact on fetal outcomes and operative success.Five databases were searched from inception to August 2023. Studies detailing post‐delivery placental analysis within TTTS twins post‐laser were included. Studies were categorized into two main groups: (1) residual anastomoses following laser and (2) abnormal cord insertion: either velamentous and/or marginal or proximate. The primary outcome was to determine the proportion of TTTS placentas with residual anastomoses and abnormal cord insertions post‐laser. Secondary outcomes included assessing residual anastomoses on post‐laser fetal outcomes and assessing the relationship between abnormal cord insertion and TTTS development. Study bias was critiqued using the Joanna Briggs Institute checklists and Cochrane risk of bias tool. Random‐effects meta‐analysis was used, and results were reported as pooled proportions or odds ratio (OR) with 95% confidence interval (CI). PROSPERO registration: CRD42023476875.Twenty‐six studies, comprising 4013 monochorionic twins, were included for analysis. The proportion of TTTS placentas with residual anastomoses following laser was 24% (95% CI, 0.12–0.41), with a mean and standard deviation of 4.03 ± 2.95 anastomoses per placenta. Post‐laser residual anastomoses were significantly associated with intrauterine fetal death (OR, 2.38 [95% CI, 1.33–4.26]), neonatal death (OR, 3.37 [95% CI, 1.65–6.88]), recurrent TTTS (OR, 24.33 [95% CI, 6.64–89.12]), and twin anemia polycythemia sequence (OR, 13.54 [95% CI, 6.36–28.85]). Combined abnormal cord (velamentous and marginal), velamentous cord, and marginal cord insertions within one or both twins following laser were reported at rates of 49% (95% CI, 0.39–0.59), 27% (95% CI, 0.18–0.38), and 28% (95% CI, 0.21–0.36), respectively. Combined, velamentous and marginal cord insertions were not significantly associated with TTTS twins requiring laser (p = 0.72, p = 0.38, and p = 0.71, respectively) versus non‐TTTS monochorionic twins.To the best of our knowledge, this is the first review to conjointly explore outcomes of residual anastomoses and abnormal cord insertions within TTTS twins following laser. A large prospective study is necessitated to assess the relationship between abnormal cord insertion and residual anastomoses development post‐laser. [ABSTRACT FROM AUTHOR]

Background: Direct surgery is an important option to treat vertebral artery (VA) stenosis. Method: A patient with symptomatic stenosis at the origin of the right VA underwent transposition of the right VA to the common carotid artery (CCA). Using the sternocleidomastoid sparing approach, the VA was anastomosed to the posterior wall of the CCA by twisting the CCA to expose its posterior wall to face the operative field. Conclusion: This approach, consisting of securing the proximal VA and then following it to its distal end, not only preserves the sternocleidomastoid muscle but also protects the sympathetic chains and thoracic duct. [ABSTRACT FROM AUTHOR]

Anastomotic leak is a significant morbidity in colorectal surgeries. The risk factors for anastomotic leakage are multifactorial with vascularity of the bowel edge playing an important role. Indocyanine green (ICG) dye emits fluorescence and this principle is used to assess the bowel edge vascularity before anastomosis. The context of the study is that even though ICG dye has been used in colorectal cancer surgery for quite a while the evidence is not strong. Most of the data on the role of ICG dye in decreasing the anastomotic leak rate in colorectal cancer surgery comes from retrospective and few prospective trials. There are a few recently published randomized controlled trials (RCT) with contrasting outcomes in this regard. This study is a narrative review of randomized control trials and trial protocols published until 31st December 2023. PubMed, Embase, and Scopus were searched with the keywords ICG, AND Colorectal surgery, AND Anastomotic leak. Four completed RCTs were found and included in this review of all search results. Most of the included studies reported the beneficial effects of ICG on the incidence of anastomotic leak rate. To conclude, the role of ICG dye is not well established in reducing anastomotic leak rates following colorectal anastomosis, but there is growing evidence to support its use. [ABSTRACT FROM AUTHOR]

Background: The intestinal wound healing process is a complex event of three overlapping phases: exudative, proliferative, and remodeling. Although some mechanisms have been extensively described, the intestinal healing process is still not fully understood. There are some similarities but also some differences compared to other tissues. The aim of this systematic review was to summarize all studies with knockout (KO) experimental models in bowel anastomoses, underline any recent knowledge, and clarify further the cellular and molecular mechanisms of the intestinal healing process. A systematic review protocol was performed. Materials and methods: Medline, EMBASE, and Scopus were comprehensively searched. Results: a total of eight studies were included. The silenced genes included interleukin-10, the four-and-one-half LIM domain-containing protein 2 (FHL2), cyclooxygenase-2 (COX-2), annexin A1 (ANXA-1), thrombin-activatable fibrinolysis inhibitor (TAFI), and heparin-binding epidermal growth factor (HB-EGF) gene. Surgically, an end-to-end bowel anastomosis was performed in the majority of the studies. Increased inflammatory cell infiltration in the anastomotic site was found in IL-10-, annexin-A1-, and TAFI-deficient mice compared to controls. COX-1 deficiency showed decreased angiogenesis at the anastomotic site. Administration of prostaglandin E2 in COX-2-deficient mice partially improved anastomotic leak rates, while treatment of ANXA1 KO mice with Ac2-26 nanoparticles reduced colitis activity and increased weight recovery following surgery. Conclusions: our findings provide new insights into improving intestinal wound healing by amplifying the aforementioned genes using appropriate gene therapies. Further research is required to clarify further the cellular and micromolecular mechanisms of intestinal healing. [ABSTRACT FROM AUTHOR]

Background: The optimal timing and surgical approach for surgical revascularization in patients with moyamoya syndrome (MMS) associated with neurofibromatosis type I (NF1) remain so far elusive. We aimed to compare the long-term clinical, radiological, and cognitive effects of different revascularization procedures in a pediatric cohort of NF1-associated MMS. Methods: We reviewed the clinical, radiological, and surgical data of 26 patients with NF1-associated MMS diagnosed at our institution between 2012 and 2022, at the clinical onset and last follow-up. Results: Indirect bypasses were performed in 12/26 patients (57.1%), while combined direct and indirect procedures in 9/26 subjects (42.9%); 5 patients did not undergo surgery. Through logistic regression analysis, pathological Wechsler Intelligence Scale for Children (WISC) at onset was found to be associated with symptom improvement at 1-year follow up (p = 0.006). No significant differences were found in long-term neurocognitive outcome and stroke rate in patients receiving combined or indirect bypass (p > 0.05). Conclusions: Currently, whether combined or indirect bypass should be considered the treatment of choice in pediatric patients with NF1-associated MMS remains unclear, as well as the optimal time approach. In our series, no significant differences were found in long-term neurocognitive outcome and stroke rate between patients treated with either of these two approaches. Clinical evidence supports the crucial role of early diagnosis and surgical revascularization in subjects with MMS-associated NF1, even in case of mildly symptomatic vasculopathy. This allows to achieve a good long-term outcome with improved intellectual function and prevention of stroke and seizure in these patients. [ABSTRACT FROM AUTHOR]

Purpose: Preserving the ileocecal valve (ICV) has shown significant benefits. We present our experience with 18 infants who underwent ileocecal valve-preservation ileocecostomy (IVPI) with an extremely short distal ileum after primary ileostomy. Methods: A retrospective analysis was conducted on IVPI cases between 2014 and 2020. Medical records were reviewed, including birth weight, age, primary diseases, length of ileus stump, surgical time and procedure, time to enteral feeding, postoperative hospital stay, and complications. Results: Eighteen patients (male: female = 12:6, median birth weight 1305 (750–4000) g, median gestational age 29 + 5 (27 + 6–39 + 6) weeks) were included in the analysis. Causes of surgery included necrotizing enterocolitis (13), ileocecal intestinal atresia (1), ileum volvulus (2), meconium peritonitis (1), and secondary intestinal fistula (1). The median corrected age of ileostomy closure was 3.2 months (2.0–8.0 months). The distance from the distal ileal stoma to the ICV ranged from 0.5 to 2 cm. The median length of the residual bowel was 90 cm (50–130 cm). ICV-plasty was performed in 3 cases due to secondary ICV occlusion or stenosis. All patients resumed feeding within 6 to 11 days after surgery. The postoperative hospital stay ranged from 12 to 108 days (median: 16.5 days). Complications included incisional infections in 2 cases, anastomotic stricture and adhesive ileus in 1 case, nosocomial sepsis and septic shock in 1 case. All children showed normal growth and development during a 6–65 month follow-up. Conclusions: IVPI is safe and feasible for infants with an extremely short distal ileal stump. ICV-plasty could be applicable for cases with ileocecal occlusion/stenosis. [ABSTRACT FROM AUTHOR]

Background Breast cancer-related lymphedema is the most common cause of lymphedema in the United States and occurs in up to 50% of individuals receiving axillary lymph node dissection (ALND). Lymphovenous bypass (LVB) at the time of ALND may prevent lymphedema, but long-term results and anastomotic patency are unclear. This study evaluates the feasibility and outcomes of performing immediate lymphatic reconstruction via coupler-assisted bypass (CAB). Methods This is a retrospective review of all patients undergoing prophylactic LVB following ALND at two tertiary care centers between 2018 and 2022. Patients were divided into cohorts based on whether they received the "standard" end-to-end (E-E) suturing or CAB technique. The primary outcome of interest was development of lymphedema. Quantitative and qualitative assessments for lymphedema were performed preoperatively and at 3, 6, 12, and 24 months postoperatively. Results Overall, 63 LVBs were performed, of which 24 lymphatics underwent immediate reconstruction via "CAB" and 39 lymphatics via "standard" end-to-end suture. Patient characteristics, including body mass index, and treatment characteristics, including radiation therapy, did not significantly differ between groups. CAB was associated with a greater mean number of lymphatics bypassed per vein (standard 1.7 vs. CAB 2.6, p = 0.0001) and bypass to larger veins (standard 1.2 vs. CAB 2.2 mm, p < 0.0001). At a median follow-up of 14.7 months, 9.1% (1/11) of individuals receiving CAB developed lymphedema. These rates were similar to those seen following standard bypass at 4.8% (1/21), although within a significantly shorter follow-up duration (standard 7.8 vs. CAB 14.7 months, p = 0.0170). Conclusion The CAB technique is a viable, effective technical alternative to the standard LVB technique. This comparative study of techniques in prophylactic LVB suggests that CABs maintain long-term patency, possibly due to the ease of anastomosing several lymphatics to single large caliber veins while reducing the technical demands of the procedure. [ABSTRACT FROM AUTHOR]

Gastric conduit necrosis is a rare but severe complication of esophageal surgery, often associated with mediastinal sepsis and high morbidity and mortality rates, as well as reduced efficacy of conservative treatments. In most cases, management involves salvage therapy, including fluid resuscitation, antibiotics, aggressive debridement, drainage of infected collections, and proximal esophageal diversion. Primary anastomosis is rarely performed. We describe a successful case wherein we salvaged a patient following a McKeown esophagectomy and gastric pull-up, who developed partial full-thickness necrosis of the gastric conduit postoperatively, along with pleural and mediastinal sepsis. We managed this situation through thoracic debridement, take-down of the anastomosis, resection of the devitalized segment of the conduit, and primary esophagogastric anastomosis. Conduit perfusion was demonstrated using ICG fluorescent angiography. This case illustrates that, once debridement and sepsis control are achieved, a primary anastomosis, if feasible, can be safely performed, potentially avoiding a two-step procedure and a second laparotomy/thoracotomy. [ABSTRACT FROM AUTHOR]

In pediatric colorectal surgery, achieving and visualizing adequate perfusion during complex reconstructive procedures are paramount to ensure postoperative success. However, intraoperative identification of proper perfusion remains a challeng. This review synthesizes findings from the literature spanning from January 2010 to March 2024, sourced from Medline/PubMed, EMBASE, and other databases, to evaluate the role of indocyanine green (ICG) fluorescence imaging in enhancing surgical outcomes. Specifically, it explores the use of ICG in surgeries related to Hirschsprung disease, anorectal malformations, cloacal reconstructions, vaginal agenesis, bladder augmentation, and the construction of antegrade continence channels. Preliminary evidence suggests that ICG fluorescence significantly aids in intraoperative decision-making by improving the visualization of vascular networks and assessing tissue perfusion. Despite the limited number of studies, initial findings indicate that ICG may offer advantages over traditional clinical assessments for intestinal perfusion. Its application has demonstrated a promising safety profile in pediatric patients, underscoring the need for larger, prospective studies to validate these observations, quantify benefits, and further assess its impact on clinical outcomes. The potential of ICG to enhance pediatric colorectal surgery by providing real-time, accurate perfusion data could significantly improve surgical precision and patient recovery. [ABSTRACT FROM AUTHOR]

(1) Background: we conducted this study to evaluate the effect of Kono-S anastomosis on postoperative morbidity after bowel resection for Crohn's disease. (2) Methods: This study adhered to the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The primary endpoint was the overall complications rate. Secondary outcomes included specific complications analyses, disease recurrence and efficiency endpoints. A systematic literature screening was performed in major electronic scholar databases (Medline, Scopus, Web of Science), from inception to 17 January 2024. Both Random (RE) and Fixed Effects (FE) models were estimated; the reported analysis was based on the Cochran Q test results. (3) Results: Overall, eight studies and 913 patients were included in this meta-analysis. Pooled analyses confirmed that Kono-S was not superior in terms of overall morbidity (OR: 0.69 [0.42, 1.15], p = 0.16). Kono-S displayed a reduced risk for anastomotic leakage (OR: 0.34 [0.16, 0.71], p = 0.004) and reoperation (OR: 0.12 [0.05, 0.27], p < 0.001), and a shortened length of hospital stay (WMD: −0.54 [−0.73, −0.34], p < 0.001). On the contrary, Kono-S results in higher rates of postoperative SSIs (OR: 1.85 [1.02, 3.35], p = 0.04). (4) Conclusions: This study confirms a comparable morbidity, but a lower risk of anastomotic leak and reoperation of Kono-S over conventional anastomoses. Further high quality studies are required to validate these findings. [ABSTRACT FROM AUTHOR]

Background: There is limited data to guide decision‐making between performing a primary anastomosis and fashioning an end colostomy following emergency sigmoid colectomy for patients with sigmoid volvulus. The aim of this study was to compare the outcomes of these two approaches. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS‐NSQIP) database from 2006 to 2021 was retrospectively analyzed. Missing data were multiply imputed, and coarsened exact matching was performed to generate matched cohorts. Rates of major complications and other postoperative outcomes were evaluated among patients who had a primary anastomosis as compared with matched controls who had an end colostomy following emergency sigmoid colectomy. Results: Overall, 4041 patients who had a primary anastomosis and 1240 who had an end colostomy met the inclusion criteria. After multiple imputation and coarsened exact matching, 895 patients who had a primary anastomosis had a matched control. The rate of major complications was lower in patients who had an end colostomy (33.2% vs. 36.7%), but this difference was not statistically significant (OR 0.86, 95% CI 0.70–1.05). Results were similar in subgroup analyses of higher‐risk patients. There were no significant differences in overall complication rate, mortality, length of hospital stay, or readmission rate. Patients with a colostomy were more likely to be discharged to a care facility (OR 1.35, 95% CI 1.09–1.67). Conclusion: Differences in rates of major complications and many other outcomes after primary anastomosis as compared with end colostomy were not statistically significant following emergency sigmoid colectomy for sigmoid volvulus. [ABSTRACT FROM AUTHOR]

OBJECTIVES Performance of a technically sound left internal thoracic artery to left anterior descending artery (LITA-LAD) anastomosis during coronary artery bypass grafting (CABG) is critically important. We used prospectively collected data from the multicentre, randomized REGROUP (Randomized Endograft Vein Perspective) trial to investigate CABG outcomes based on whether a resident or an attending surgeon performed the LITA-LAD anastomosis. METHODS This was a post hoc subanalysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest from 2014 through 2017. The primary end point was major cardiac adverse events, defined as the composite of all-cause deaths, nonfatal myocardial infarctions or repeat revascularizations. RESULTS Among 1,084 patients, 344 (31.8%) LITA-LAD anastomoses were performed by residents and 740 (68.2%), by attending surgeons. Residents (compared to attendings) operated on fewer patients with high tercile SYNTAX scores (22.1% vs 37.4%, P  < 0.001), performed fewer multiarterial CABGs (5.2% vs 14.6%, P  < 0.001) and performed more anastomoses to distal targets with diameters > 2.0 mm (19.0% vs 10.9%, P  < 0.001) and non-calcified landing zones (25.1% vs 21.6%, P  < 0.001). During a median observation time of 4.7 years (interquartile range 3.84–5.45), major cardiac adverse events occurred in 77 patients (22.4%) in the group treated by residents and 169 patients (22.8%) in the group treated by attendings (unadjusted HR 1.00; 95% confidence interval, 0.76–1.33; P  = 0.99). Outcomes persisted on adjusted analyses. CONCLUSIONS Based on this REGROUP trial subanalysis, under careful supervision and with appropriate patient selection, LITA-LAD anastomoses performed by the residents yielded clinical outcomes similar to those of the attendings. [ABSTRACT FROM AUTHOR]

The description of anastomosis of the phrenic nerve has been little studied and even controversial at present. Classical authors such as Testut have briefly described this anastomosis. 13 anatomical preparations formalized at 10% were used, identifying 26 phrenic nerves from their location in the neck and being dissected to their terminal distribution in the diaphragm muscle. A distribution of the phrenic nerve was observed in 3 terminal branches, anterior, lateral and posterior. These branches penetrate the muscle and run initially between the muscle fibers and then on the underside of the muscle and the fascia. In monitoring the anterior branch of the phrenic nerve, it was found that it divided into several branches. 2 constantly stood out, one anterior towards the sternum and another medial that borders the pericardium, which was of interest to us. In 38% of the cases, anastomoses were found between the right and left phrenic nerves, located mainly anterior to the pericardium, which would indicate a justification for reinnervation due to damage to the phrenic. This anatomical description is of utmost importance in cases of bilateral injury to the phrenic nerve and explains the recovery of the denervated diaphragm. [ABSTRACT FROM AUTHOR]

Copyright of Turkish Journal of Trauma & Emergency Surgery / Ulusal Travma ve Acil Cerrahi Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Purpose: Gastrointestinal disorders frequently necessitate surgery involving intestinal resection and anastomosis formation, potentially leading to severe complications like anastomotic leakage (AL) which is associated with increased morbidity, mortality, and adverse oncologic outcomes. While extensive research has explored the biology of anastomotic healing, there is limited understanding of the biomechanical properties of gastrointestinal anastomoses, which was aimed to be unraveled in this study. Methods: An ex-vivo model was developed for the biomechanical analysis of 32 handsewn porcine end-to-end anastomoses, using interrupted and continuous suture techniques subjected to different flow models. While multiple cameras captured different angles of the anastomosis, comprehensive data recording of pressure, time, and temperature was performed simultaneously. Special focus was laid on monitoring time, location and pressure of anastomotic leakage (LP) and bursting pressures (BP) depending on suture techniques and flow models. Results: Significant differences in LP, BP, and time intervals were observed based on the flow model but not on the suture techniques applied. Interestingly, anastomoses at the insertion site of the mesentery exhibited significantly higher rates of leakage and bursting compared to other sections of the anastomosis. Conclusion: The developed ex-vivo model facilitated comparable, reproducible, and user-independent biomechanical analyses. Assessing biomechanical properties of anastomoses offers an advantage in identifying technical weak points to refine surgical techniques, potentially reducing complications like AL. The results indicate that mesenteric insertion serves as a potential weak spot for AL, warranting further investigations and refinements in surgical techniques to optimize outcomes in this critical area of anastomotic procedures. [ABSTRACT FROM AUTHOR]

Objectives: Redo surgery for pelvic fracture urethral distraction defects (PFUDDs) is still a challenge. the long urethral defect makes it difficult while the high tension increase the recurrence rate. Although certain ancillary maneuvers can relieve tension, there is no consensus or guidelines for the prediction/planning of the selection. In this study, we present our experience with developing an intraoperative guidance system to achieve tension-free urethral anastomosis. Patients and methods: A total of 91 recurrent PFUDD patients managed at our center between 2020 and 2022 were retrospectively analyzed. The patients underwent scar removing and urethral anastomosis. For the long defect and high-tension cases, 6 kinds of tension-relieving maneuvers were used respectively during the process of urethral anastomosis. Preoperative assessment of the urethrogram was done before surgery, while biaxial (vertical and horizontal) defect measurements were performed intraoperatively. The patients were followed-up for 12 months (8.9 ± 4.2), furthermore, recurrence and complications were analyzed. Results: The overall success rate was 86.81%. The mean defect in urethrogram was 2.9 ± 1.1 cm. 27 simple anastomosis was performed when the vertical plus horizontal defect was less than 2 cm with 11.11% recurrence. 24 cavernous septum splittings were performed when the horizontal defect was greater than 2 cm with 8.33% recurrence. 21 inferior pubectomies were performed when the horizontal defect was greater than 3 cm with 19.05% recurrence. 15 ancillary distal urethra manipulations (fully distal urethral mobilization, urethral suspension and corpus cavernosa folding) were performed when the vertical defect was 3 to 4 cm with 13.33 recurrence. 4 reroutings were performed when the vertical defect was greater than 4 cm with 25.00% recurrence. Conclusions: Ancillary maneuvers are effective for reducing tension in redo urethral anastomosis. Measurement of divergent vertical and horizontal urethral defects could guide the selection of ancillary maneuvers. Combined tension-relieving maneuvers is recommended according to the defect direction and length to achieve a tension-free anastomosis. [ABSTRACT FROM AUTHOR]

Introduction: Minimally invasive colonic anastomosis can be performed intracorporeally or extracorporeally with laparoscopic or robotic assistance. In colorectal surgery, choosing the optimal approach is still controversial. Mainly, the debate involves balancing the potential benefits of intracorporeal anastomosis (ICA) with increased technical difficultly with the more straightforward and widely accepted extracorporeal anastomosis (ECA). Both techniques require different skill sets, and this study aims to identify barriers that prevent adoption of ICA. Methods: A 31‐point questionnaire survey was distributed through the General Surgeons Australia (GSA) platform of active general surgeon in Australia. It was open for 2 months between July and August 2023. Statistical analysis was completed using descriptive analysis and logistic regression. Results: Forty‐three general surgeons completed the survey. ECA was the most performed and preferred surgical technique. It was identified that increased operative time is the biggest barrier to completing ICA followed by lack of training and no perceived benefit with ICA. Patient comorbidities did not result in choosing ICA over ECA; however, surgeons with less experience and volume in colorectal surgery were more likely complete ECA in operations with increased technical difficulty. Conclusion: Although ECA is the go‐to technique for many Australian general surgeons, it is evident that they may be overlooking the benefits offered by ICA. Further training is required to improve operative times and confidence in the technique. Ongoing research, audits of existing techniques, and updated training will assist surgeons becoming acquainted with the latest evidence and to offer the best care to their patients. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the clinical prevalence, characteristics, and relevance of the corona mortis (CM) in anterior approaches to the pelvis and acetabulum. Methods: Retrospective analysis of 185 theater reports from patients (73 females; mean age 62.8 ± 17.2 years) who underwent surgeries for pelvic ring injuries, acetabular fractures, or combined injuries using anterior approaches (Modified Stoppa or Pararectus) at our institution between 01/2008 to 12/2022. During procedures, the CM was routinely identified, evaluated, and occluded. Bilateral exposure of the superior pubic branch in 25 cases led to 210 hemipelvises analyzed. Exclusions: CM not mentioned in report and revisions via the initial approach. Results: In the 210 hemipelvises examined, the prevalence of any CM vessel was 81% (170/210). Venous anastomoses were found in 76% of hemipelvises (159/210), arterial in 22% (47/210). Sole venous anastomoses appeared in 59% (123/210), sole arterial in 5% (11/210). Both types coexisted in 17% (36/210), while 19% (40/210) had none. A single incidental CM injury occurred without significant bleeding. In ten cases, trauma had preoperatively ruptured the CM, but bleeding was readily managed. Females had a significantly higher CM prevalence than males (p = 0.001). Conclusion: Our findings show a CM prevalence aligning more with anatomical studies than prior intraoperative series. Although we observed one incidental and ten trauma-related CM injuries, we did not encounter uncontrollable bleeding. Our data suggest that in anterior pelvic approaches, when the CM is actively identified and occluded, it is not associated with bleeding events, despite its high prevalence. [ABSTRACT FROM AUTHOR]

Aim: The Kono‐S anastomosis was introduced as a possible solution to the high surgical recurrence rates in Crohn's disease. However, this technique is known to be challenging, which is why it was originally performed in an extracorporeal setting. The aim of this case series was to assess safety, in terms of intra‐/postoperative complications, and feasibility, in terms of successful performance of anastomosis, of a robot‐assisted intracorporeal Kono‐S anastomosis. Method: This is a prospective single‐centre consecutive case series. Patients were considered eligible if they were diagnosed with refractory Crohn's disease with significant bowel stenosis of the terminal ileum. All patients underwent robot‐assisted intracorporeal Kono‐S anastomosis. Perioperative care was provided according to the Enhanced Recovery After Surgery® protocol. Follow‐up for postoperative complications was 30 days. Results: Twenty patients were included, of whom 11 (55%) were men. The median age was 30 years [interquartile range (IQR) 22–51 years] and the median BMI was 25 kg/m2 (IQR 19–28 kg/m2). Intracorporeal Kono‐S anastomosis was successfully performed in all cases. The median operating time was 155 min (IQR 144–176 min) and the median length of stay was 3 days (IQR 1–5 days). No conversions or 30‐day mortality were observed. One patient experienced anastomotic leakage, which was treated with radiologically guided drainage. A total of three patients experienced postoperative complications in the first 30 days. Conclusion: Performance of intracorporeal robot‐assisted Kono‐S anastomosis seems safe and feasible in this case series for Crohn's disease. Since this is a first case series, further research is required to confirm results in a larger population‐based cohort. [ABSTRACT FROM AUTHOR]

Introduction: In minimally invasive esophagectomy, a circular stapled anastomosis is common, but no evidence exists investigating the role of the specific localization of the anastomosis. The aim of this study is to evaluate the impact of an esophagogastrostomy on the anterior or posterior wall of the gastric conduit on the postoperative outcomes. Material and methods: All oncologic minimally invasive Ivor Lewis procedures, performed between 2017 and 2022, were included in this study. The cohort was divided in two groups: a) intrathoracic esophagogastrostomy on the anterior gastric wall of the conduit (ANT, n = 285, 65%) and b) on the posterior gastric wall (POST, n = 154, 35%). Clinicopathological parameters and short-term outcomes were compared between both groups by retrieving data from the prospective database. Results: Overall, 439 patients were included, baseline characteristics were similar in both groups, there was a higher proportion of squamous cell carcinoma in ANT (22.8% vs. 16.2%, P = 0.043). A higher rate of robotic-assisted procedures was observed in ANT (71.2% vs. 49.4%). Anastomotic leakage rate was similar in both groups (ANT 10.4% vs. POST 9.8%, P = 0.851). Overall complication rate and Clavien–Dindo > 3 complication rates were higher in POST compared to ANT: 53.2% vs. 40% (P = 0.008) and 36.9% vs. 25.7% (P = 0.014), respectively. The rate of delayed gastric emptying (20.1% vs. 7.4%, P < 0.001) and nosocomial pneumonia (22.1% vs. 14.8%, P = 0.05) was significantly higher in POST. Conclusion: Patients undergoing minimally invasive Ivor Lewis esophagectomy with an intrathoracic circular stapled anastomosis may benefit from esophagogastrostomy on the anterior wall of the gastric conduit, in terms of lower rate of delayed gastric emptying. [ABSTRACT FROM AUTHOR]

Background: An anastomotic stricture after colorectal surgery is principally managed by endoscopic balloon dilation (EBD). Although this intervention is effective, however, subsequent procedures or surgical interventions are often required. This study aimed to assess the long-term outcomes of EBD for anastomotic stricture arising from colorectal cancer surgery. Materials and methods: We analyzed 173 patients who received curative surgery for colorectal cancer at our hospital between January 2000 and December 2022 and had undergone EBD to manage anastomotic stricture. The medical records of these cases were retrospectively reviewed to assess the outcomes and risk factors for restenosis and permanent stoma. Results: Of the 173 study patients, 41 (23.7%) presented with restenosis with a median time to recurrence of 49 [37–150] days. The restenosis group was significantly younger (55.6 years versus 60.8 years), with a more prominent rectal location (80.5% versus 57.6%), a higher incidence of hand-sewn anastomosis (24.4% versus 5.3%), and a higher percentage of neoadjuvant radiotherapy (34.1% versus 5.3%, P < 0.001). Multivariable analysis indicated neoadjuvant radiotherapy (adjusted HR 2.48; 95% CI 1.03–5.95) and cerebral vascular disease (adjusted HR 6.97; 95% CI 2.15–22.54) as independent prognostic factors for restenosis. Fourteen patients (8.1%) required a permanent stoma due to treatment failure. All cases needing a permanent stoma were male (14 patients, 100%, P = 0.007) and this group had a higher rate of neoadjuvant radiotherapy, adjuvant chemotherapy, and hand-sewn anastomosis. Conclusion: Patients receiving neoadjuvant radiotherapy are most prone to restenosis after an EBD intervention to manage an anastomotic stricture. Neoadjuvant radiotherapy is also a strong risk factor for requiring a permanent stomas due to treatment failure. [ABSTRACT FROM AUTHOR]

Background: Approach to enteric anastomotic technique has been a subject of debate, with no clear consensus as to whether handsewn or stapled techniques are superior in trauma settings, which are influenced by unique perturbances to important processes such as immune function, coagulation, wound healing and response to infection. This systematic review and meta‐analysis compares the risk of anastomotic complications in trauma patients with gastrointestinal injury requiring restoration of continuity with handsewn versus staples approaches. Methods: A comprehensive computer assisted search of electronic databases Medline, Embase and Cochrane Central was performed. Comparative studies evaluating stapled versus handsewn gastrointestinal anastomoses in trauma patients were included in this review. All anastomoses involving small intestine to small intestine, small to large intestine, and large intestine to large intestine were eligible. Anastomosis to the rectum was excluded. Outcomes evaluated were (1) anastomotic leak (AL) (2) a composite anastomotic complication (CAC) end point consisting of AL, enterocutaneous fistula (ECF) and deep abdominal abscess. Results: Eight studies involving 931 patients were included and of these patients, data from 790 patients were available for analysis. There was no significant difference identified for anastomotic leak between the two groups (OR = 0.77; 95% CI 0.24–2.45; P = 0.66). There was no significant improvement in composite anastomotic complication; defined as a composite of anastomotic leak, deep intra‐abdominal abscess and intra‐abdominal fistula, in the stapled anastomosis group (OR = 1.05; 95% CI 0.53–2.09; P = 0.90). Overall, there was limited evidence to suggest superiority with handsewn or stapled anastomosis for improving AL or CAC, however this was based on studies of moderate to high risk of bias with poor control for confounders. Discussion: This meta‐analysis demonstrates no superiority improvement in anastomotic outcomes with handsewn or stapled repair. These findings may represent no effect in anastomotic outcome by technique for all situations. However, considering the paucity of information on potential confounders, perhaps there is a difference in outcome with overall technique or for specific subgroups that have not been described due to limited sample size and data on confounders. Currently, there is insufficient evidence to recommend an anastomotic technique in trauma. [ABSTRACT FROM AUTHOR]

Background. The widespread use of functional endoscopic intervention in the nasal cavity requires detailed knowledge of the variant anatomy of the structures of the paranasal sinuses, taking into account age and gender, necessary to improve surgical treatment. In order to determine the variants of the structure of the anastomosis and intra-sinus septa of the maxillary sinus in childhood, a study was conducted of 425 computed tomograms of the heads of children aged 1 to 21 years of both sexes without pathology of the paranasal sinuses. Results and conclusions. It has been established that, regardless of gender, the width of the anastomosis of the maxillary sinus increases in each subsequent age group, with the largest increase at 2–3 years and 8–12 years and has no bilateral or gender differences. Intra- sinus bone septa in the first and second childhood ages were determined only in girls. In adolescence and adolescence - in persons of both sexes, and the frequency of occurrence increases with age in boys and young men. In the right maxillary sinus, incomplete and complete septa were identified, in the left - only incomplete. The greatest number of septa was observed in adolescence on the right. Intra-sinus septa can divide the sinus into two or more chambers of varying sizes, which remain connected to each other, creating difficulties during surgery. Thus, variants of the anatomical structure of the intra- sinus septa in children have been identified, associated with gender, age and side of the skull, while the variability of the width of the anastomosis depends only on age.

Extended distal pancreatectomy often requires resection of vascular structures and adjacent organs, potentially leading to gastric venous congestion. This case report describes a 49-year-old female who underwent radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma. During the procedure, segmental gastric venous congestion was observed and resolved by anastomosing the left gastric vein to the left adrenal vein. The in-hospital postoperative recovery was initially uneventful; however, the patient was readmitted because of intra-abdominal fluid collection that was managed with antibiotics. Pathological examination confirmed moderately differentiated ductal adenocarcinoma with lymphovascular invasion. The patient received adjuvant mFOLFIRINOX therapy and remains disease-free 12 months after surgery with adequate patency of the anastomosis. This case highlights the importance of recognizing and addressing gastric venous congestion during radical antegrade modular pancreatosplenectomy to prevent complications, such as delayed gastric emptying or gastric necrosis, and proposes left gastric vein to left adrenal vein anastomosis as an effective intraoperative solution. [ABSTRACT FROM AUTHOR]

Gastrointestinal stromal tumors (GISTs) are uncommon tumors typically found in the stomach, with an even rarer appearance in the jejunum. These tumors are often discovered incidentally, given their nonspecific presentation. We present a case of chronic iron deficiency anemia in a patient with symptomatic GIST involving the proximal jejunum requiring robot-assisted resection with primary anastomosis. Pathological examination of the excised GIST revealed positive immunoreactivity for cKIT, DOG1, and CD37. This case highlights the importance of considering GIST as a differential diagnosis for chronic anemia and emphasizes the critical role of CT imaging in its detection and management. [ABSTRACT FROM AUTHOR]

Purpose: To describe a case of combined duplicate origin and early bifurcated middle cerebral artery (MCA) incidentally diagnosed using magnetic resonance (MR) angiography. Methods: A 51-year-old woman with an unruptured left MCA aneurysm underwent cranial MR angiography with a 3-Tesla scanner for presurgical evaluation. MR angiography was performed using a standard 3-dimensional time-of-flight technique. Results: An unruptured left MCA aneurysm at the M1-M2 junction was identified. The maximum aneurysm diameter was 9 mm. Two almost equally sized right MCAs arose from the terminal segment of the right internal carotid artery. These two channels soon anastomosed, and the temporal branch arose from the inferior channel. The aneurysm was successfully treated with coil embolization. Conclusion: We herein report a case of a combined duplicate origin and early bifurcated MCA. This variation can also be regarded as anastomosis between the main MCA and the duplicated MCA. This variation has been previously reported as segmental duplication of the MCA. This is the third case of this rare MCA variation reported in the relevant English-language literature. The term "segmental duplication" may be confused with duplicate origin of the MCA, in which only one artery is located distal to the fusion. [ABSTRACT FROM AUTHOR]