Surgeries, Volume 4, Issue 1 (March 2023) – 15 articles

Gastric diverticula are uncommon anatomic abnormalities that are usually asymptomatic or found incidentally in upper gastrointestinal radiographs with contrast or endoscopy. Gastric diverticula usually arise from the wall of the gastric fundus. Their preoperative study or intraoperative finding is of great importance in patients with obesity who are scheduled for bariatric surgery. In bariatric surgery, and especially in sleeve gastrectomy, it is of utmost importance to know the exact location of the diverticulum in order to position the stapler correctly and to perform appropriate gastric resection including the diverticulum. Sleeve gastrectomy has gained popularity worldwide and currently accounts for the most performed bariatric procedure according to more recent international surveys. It is considered to be a technically easy procedure. Nonetheless, some steps of the procedure, such as gastric fundus mobilization and the gastric resection with the use of the stapler, may be challenging in patients with a high BMI and in the presence of abnormalities of the gastric wall. This can represent a risk for the occurrence of complications such as a gastric leak or bleeding. We propose some considerations about technical tips to adopt for safely performing sleeve gastrectomy in the presence of a subcardial diverticulum. Full article

Primary focal hyperhidrosis is an idiopathic condition characterized by excessive sweating, predominantly localized in the hands and armpits. This condition affects about 1% of the general population and it is often associated with a deterioration of the Quality of Life (QoL), especially in younger patients. Medical therapy, usually prescribed as a first approach, is associated with good results, but only in the short term. Surgery, on the other hand, is associated with a definitive resolution of the disease in most patients. Currently, there is no consensus on the timing of treatment and the final decision is often at the discretion of the physician and the patient. The aim of this study is to analyze the post-operative, age-related QoL in patients affected by primary hyperhidrosis treated by surgery by analyzing data of 56 patients who underwent biportal thoracoscopic sympathectomy between January 2016 and October 2019, dividing the patients into two groups: under and over the age of 25. The QoL was studied by administering the IIRS questionnaire pre-operatively and then six months after surgery. Data analysis demonstrated a lower complication rate in younger patients and equal post-operative outcomes in the two age groups. Full article

Lumbosacral transition vertebra (LSTV) is a common occurrence and its prevalence ranges from 2.6% to 35.6%. Our aim is to study this phenomenon in the adult Singaporean population and assess the level of degeneration of the suprajacent disc in those with LSTV. Retrospectively, 545 patients (Age = 57.6 ± 18.3 years; Male = 277; Female = 268) who underwent radiographic evaluation of the lumbar spine for lower back pain or radicular symptoms were shortlisted. LSTV was found to be present in 106 patients (19.4%) with sacralization of L5 and lumbarization of S1 occurring in 96 patients (17.6%) and 10 patients (1.8%), respectively. The most common form of LSTV was Castellvi type IIA (46 patients; 43.4%). Based on Pfirrmann grading, Grade IV disc degeneration was most common in both the LSTV level (63%) and the unfused suprajacent level (77%) in those with LSTV. There was a significantly higher number of patients with grade IV and above degeneration in the suprajacent disc level among those with LSTV when compared to the last unfused (L5-S1) disc level in those without LSTV (84% vs. 65%; p = 0.0001). This suprajacent disc degeneration seen in patients with LSTV may contribute to low back pain and related problems in these patients. Full article

Lip carcinoma is one of the most frequent conditions affecting the general population. It is among the ten most common neoplasms, but despite advances in research and therapy, its prognosis has not improved in a significant way in the past few years, making it a challenge in the medical research field and in surgical treatment. This study was conducted with the aim of evaluating the available reconstructive surgical options for the treatment of lip carcinomas in order to define which could be the most appropriate technique to achieve satisfying aesthetic and functional outcomes considering hospital resources in the COVID-19 era. Seventeen patients were included in this retrospective study, which took place between January 2019 and April 2021. There were two groups: seven patients who underwent a radial forearm free flap and ten who underwent locoregional flaps. The statistical analysis was performed to evaluate four different endpoints. Surgical length, ICU stay, and hospitalization time were minor for locoregional flaps. There was no statistically significant difference between the two groups when considering post-operative complications. Locoregional flaps have a more aesthetically pleasing result, but from a functional point of view, the results can be superimposable. Both techniques are associated with adequate speech, mouth opening, sealing, and symmetry. Given the impact of the COVID-19 pandemic on the healthcare system, locoregional flaps have been proven to be a good surgical option in the reconstruction of lip defects both in terms of aesthetics and functional outcome. Full article

The laparoscopic intraperitoneal onlay mesh repair (IPOM) approach has become the most widely adopted technique in the last decade. The role of laparoscopic IPOM in the last years has been resizing due to several limitations. The aim of the present study is to evaluate short- and long-term outcomes in patients who underwent laparoscopic IPOM. This retrospective single-center study describes 170 patients who underwent laparoscopic IPOM for ventral hernia at the General Surgery Unit of Parma University Hospital from 1 January 2016 to 31 December 2020. We evaluated patient, hernia, surgical and postoperative characteristics. According to the defect size, we divided the patients into Group 1 (Ø < 30 mm), Group 2 (30 < Ø < 50 mm) and Group 3 (Ø > 50 mm). A total of 167 patients were included. The mean defect diameter was 41.1 ± 16.3 mm. The mean operative time was different among the three groups (p < 0.001). Higher Charlson Comorbidity Index, obesity and incisional hernia were related to postoperative seroma and obesity alone with SSO. p < 0.001 Recurrence was significantly higher in larger defects (Group 3) and incisional hernia. p < 0.001. This retrospective study suggests that laparoscopic IPOM is a feasible and safe surgical technique with an acceptable complication rate, especially in the treatment of smaller defects up to 5 cm. Full article

(1) Background: Artificial Intelligence (AI) is transforming healthcare on all levels. While AI shows immense potential, the clinical implementation is lagging. We present a concise review of AI in surgical learning; (2) Methods: A non-systematic review of AI in surgical learning of the literature in English is provided; (3) Results: AI shows utility for all components of surgical competence within surgical learning. AI presents with great potential within robotic surgery specifically; (4) Conclusions: Technology will evolve in ways currently unimaginable, presenting us with novel applications of AI and derivatives thereof. Surgeons must be open to new modes of learning to be able to implement all evidence-based applications of AI in the future. Systematic analyses of AI in surgical learning are needed. Full article

A 70-year-old man was admitted to the Emergency Department (ED) for marked asthenia and severe anemia. In addition, a high level of lipase was found. During hospitalization, a locally advanced gastric cancer was diagnosed, with endoscopic evidence of a large polyploid formation originating under the cardias that occupied most of the gastric lumen. A total body CT scan was performed before surgery; the tumor affected the posterior gastric wall, with tenacious infiltration of the pancreatic body. Therefore, we performed a total gastrectomy with esophageal jejunum anastomosis and reconstruction of intestinal continuity according to Roux, distal spleno-pancreatectomy, and cholecystectomy. At histology, a pancreatic acinar cell carcinoma (PACC) with full thickness infiltration of the gastric wall was diagnosed. Acinar cell carcinomas are highly aggressive neoplasms, and surgical resection, when feasible, is the treatment of choice regardless of size, also because the role of neoadjuvant or adjuvant chemo- or radiotherapy remains uncodified. Full article

The complex geometries and material properties necessary for generating accurate organ mimics require new procedures and methods to fully utilize current technologies. The increased accessibility of 3D printers, along with more specialized bioprinters, allow the creation of highly tunable models of various body parts. Three-dimensional printing can reduce lead-time on custom parts, produce structures based on imaging data in patients, and generate a test bench for novel surgical methods. This technical note will cover three unique case studes and offer insights for how 3D printing can be used for lab research. Each case follows a unique design process in comparison to traditional manufacturing workflows as they required significantly more iterative design. The strengths of different printing technologies, design choices, and structural/chemical requirements all influence the design process. Utilization of in-house manufacturing allows for greater flexibility and lower lead-times for novel research applications. Detailed discussions of these design processes will help reduce some of the major barriers to entry for these technologies and provide options for researchers working in the field. Full article

Over the past few decades, surgeon training has changed dramatically. Surgical skills are now taught in a surgical skills laboratory instead of the operating room. Simulation-based training helps medical students improve their skills, but it has not revolutionized clinical education. One critical barrier to reaching such a desired goal is the lack of reliable, robust, and objective methods for assessing the effectiveness of training sessions and the development of students. In this paper, we will develop a new comparative analysis approach that employs network models as the central concept in establishing a new assessment tool for the evaluation of the surgical skills of trainees as well as the training processes. The model is populated using participants electromyography data while performing a simulation task. Furthermore, using NASA Task Load Index score, participants’ subjective overload levels are analyzed to examine the impact of participants’ perception of their mental demand, physical demand, temporal demand, performance, effort, and frustration on how participants perform each simulation task. Obtained results indicate that the proposed approach enables us to extract useful information from the raw data and provides an objective method for assessment the of surgical simulation tasks and how the participants’ perception of task impacts their performance. Full article

We report a patient who was referred to the emergency room with pulmonary complaints and where a computed tomography (CT) scan showed an unexpected 12.6 cm nail in the thorax penetrating part of the left pulmonary upper lobe, the left pulmonary artery, the left main bronchus, and the descending aorta, which had been in situ for at least three days. The quickly deteriorating patient had to be transferred to a tertiary academic hospital where the nail was successfully surgically removed. The comprehensive description of this unique case with a discussion of the critical decision moments could render insights into the management of challenging trauma cases. Full article

Introduction with Aim: Postoperative respiratory depression can complicate a patient’s recovery after surgery. A predictive score (PRODIGY) was recently proposed to evaluate the risk of opioid-induced postoperative respiratory depression. For the first time, we applied this score to a cohort of patients receiving bariatric surgery, stratified by Obstructive Sleep Apnea (OSA) status. In addition, we recorded continuous postoperative capnography to evaluate respiratory depression and apnea episodes (Respiratory Events, RE). Materials and Methods: The present study was approved by our IRB and comprised continuous surveillance of respiratory variables during postoperative recovery (in PACU) after robotic bariatric surgery. We utilized continuous capnography and pulse oximetry (Capnostream 35, Medtronic Inc., and Profox Respiratory Oximetry software). Preoperative preparation included OSA evaluation for all bariatric patients, additional sleep studies for severe OSA grades, and evaluation of risk for respiratory depression (low, intermediate, or high) using the published PRODIGY score. In addition, we evaluated patients by OSA status. All patients received multimodal intraoperative non-opioid anesthesia from the same team. After surgery, all patients received continuous respiratory surveillance in PACU (average duration exceeding 140 min). Respiratory depression events were scored using a modified list of the five standard published categories. Events were measured according to analysis of continuously recorded tracing of the compiled respiratory variables by observers kept blind from the study patient’s group. Results: Of the 80 patients evaluated (18 male), 56 had obstructive sleep apnea and were using CPAP at home (OSA); 24 did not. OSA patients received CPAP via an oronasal mask or a nasal pillow pressure support immediately after arriving in PACU, utilizing their at-home settings. We encountered 115 respiratory depression events across 48 patients. The most frequent respiratory event recorded was a transient desaturation (as low as 85%), which usually lasted 20–30 sec and resolved spontaneously in 3 to 5 min; most episodes followed small boluses of IV opioid analgesia administered during recovery, on demand. All episodes resolved spontaneously without any nursing or medical intervention. OSA patients had significantly more events than non-OSA patients (1.84 (1.78–1.9) mean events vs. 0.50 (0.43–0.57) for non-OSA, p = 0.0002). The level of PRODIGY score (low, intermediate, or high), instead, was not predictive of the number of events when we treated this variable as continuous (p = 0.39) or categorical (high vs. low, p = 0.65, and intermediate vs. low, p = 0.17). Conclusions: We attribute these novel results, showing a lack of respiratory events requiring intervention, to opioid-free anesthesia, early CPAP utilization, and head-up positioning on admission to PACU. Furthermore, all these patients had light postoperative narcotic requirements. Finally, an elevated PRODIGY score in our patients did not sufficiently predict respiratory events, but OSA status alone did. Key Points Summary: We investigated the incidence of Respiratory Events (RE) in Obstructive Sleep Apnea patients after surgery (56 patients) and compared them to similar patients without OSA (24 patients). All patients received identical robotic-assisted surgery and low- or no-opiate anesthesia. Patients were pre-screened with the standard published PRODIGY scores and were monitored after PACU arrival with continuous oximetry and capnography (Capnostream 35 and Profox analysis). OSA patients showed more RE than non-OSA (1.8 vs. 0.5, p = −0.0002). However, patients with elevated PRODIGY scores did not develop more frequent RE compared to patients with low scores. We attribute these novel results to opioid-sparing anesthesia/analgesia and immediate CPAP utilization on admission to PACU. Full article

Dunbar syndrome is caused by the compression of the celiac artery by the median arcuate ligament (MAL) and the diaphragmatic crura, presenting with abdominal pain. The treatment is surgical, with the aim of dissecting and separating the diaphragmatic crura from the celiac axis, restoring blood flow in the celiac trunk. We propose the use of transesophageal echocardiography to measure the peak systolic velocity in the celiac trunk and to evaluate, in real time, the efficacy of the surgery during MAL resection. Two clinical cases with practical implications are reported. In one of these, the ultrasound exam was useful in providing an intraoperative confirmation of the outcome of the resection. Full article

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare variant of mullerian duct anomalies characterized by the triad of uterine didelphys, obstructed hemivagina and ipsilateral renal agenesis. We report two cases of HWW syndrome in young women with abdominal pain. This diagnosis can easily be missed if a clinician is not aware of the syndrome. In one case, the computed tomography image of obstructed hemivagina with hematocolpos was initially mistaken for a cystic tumor of adnexa by the radiologist; in the other case, correct diagnosis was missed for years despite numerous visits to different hospitals due to lack of awareness of the syndrome. Full article

The general improvement in life expectancy and standard of living makes it easier for patients to get access to routine medical exams and is anticipated to increase the prevalence of several degenerative joint illnesses. In addition, it is anticipated that their incidence will increase both nationally and internationally, which will raise the demand for novel and long-lasting implantable devices in the field of orthopedics. The current review’s goals are to define what constitutes a biocompatible orthopedic implant in terms of in vitro biocompatibility testing and to clarify important concepts and definitions that are already in use. The demand for materials and implants made of various tissues is now increasing, and the ongoing advancement of in vitro cell culture studies is a reliable practical tool for examining the biocompatibility of potential implantable materials. In vitro biocompatibility research has been reduced and, in most cases, diminished to laboratory studies that no longer or drastically reduce animal sacrifice as a response to the well-known three “Rs” (“reduction”, “refinement”, and “replacement”) introduced to literature by English academics in the 1960s. As technology advances at an astounding rate, a new generation of gene-activating biomaterials tailored for specific people and disease conditions might emerge in the near future. Full article