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2.  Solitary scalp metastasis – a rare presentation of hepatocellular carcinoma 
Hepatocellular carcinoma (HCC) is among the commonest cancers in the world. Metastasis is one of the most significant factors affecting prognosis. Common sites of extrahepatic metastases include lungs, regional lymph nodes and less commonly bone.
Case presentation
A 56-year-old male presented with a painless occipital scalp lump of three months duration, with recent rapid enlargement. His skull x-ray showed a lytic lesion over occipital bone and the contrast CT scan of the brain showed a scalp mass with destruction of the adjacent skull. Core biopsy of the lesion revealed a metastatic deposit from a hepatocellular carcinoma.
Primary presentation with skeletal metastases are rare in HCC with only a few reported cases. Here we report a case of HCC presenting as a solitary scalp lump.
PMCID: PMC4461905  PMID: 26064186
Hepatocellular carcinoma; Skull metastasis
3.  An experimental study of the effect of pre-operative administration of cilostazol on random skin flap survival in rats: double blinded randomized controlled trial 
Insufficient arterial blood flow is the one cause of flap necrosis. Cilostazol is an inhibitor of phosphodiesterase III and increases cyclic AMP level in vascular smooth muscle cell causing vasodilation. Therefore, effect of cilostazol is expected to improve the viability of the flap.
Double blinded randomized controlled trial was conducted. The study was to compare the survival of dorsal rat flaps between preoperative cilostazol supplemented diet and regular diet. The flap survival area was measured using PixArea Image software on post operative day 1,3,5 and 7. Fluorescein injection was performed to evaluate the exactly area of flap survival on postoperative day 7 and morphology of arterioles and venules were examined by histopathologic examination.
A statistical significance was found in the percentage of area of flap survival between cilostazol supplemented diet and control group on postoperative day 3, 5 and 7 (p < 0.05). Fluorescein injection showed the higher area of flap survival in cilostazol group than the control group (p < 0.05). Histopathologic examination showed dilation of vessels in the cilostazol group.
Preoperative cilostazol in rats can enhance skin flap survival.
Electronic supplementary material
The online version of this article (doi:10.1186/s13022-015-0011-4) contains supplementary material, which is available to authorized users.
PMCID: PMC4416283  PMID: 25937828
Cilostazol; Random skin flap in rats; Flap survival
4.  Bone-added periodontal plastic surgery: a new approach in esthetic dentistry 
This article proposes a combined technique including bone grafting, connective tissue graft, and coronally advanced flap to create some space for simultaneous bone regrowth and root coverage.
A 23 year-old female was referred to our private clinic with a severe class II Miller recession and lack of attached gingiva. The suggested treatment plan comprised of root coverage combined with xenograft bone particles.
The grafted area healed well and full coverage was achieved at 12-month follow-up visit. Bone-added periodontal plastic surgery can be considered as a practical procedure for management of deep gingival recession without buccal bone plate.
PMCID: PMC4355546  PMID: 25763099
Plastic surgery; Root coverage; Periodontal regeneration; Bone graft
5.  Outcome-volume relationships and transhiatal esophagectomy: minimizing “failure to rescue” 
The objective of this study is to describe the system and technical factors that enabled our moderate size transhiatal esophagectomy program to achieve low mortality rates.
A retrospective chart review was conducted on 200 consecutive patients who underwent transhiatal esophagectomy at Robert Wood Johnson University Hospital. Primary outcomes included operative times, estimated blood loss, frequency and nature of complications, and lengths of stay in the hospital and the intensive care unit.
In general, surgical outcomes tended to improve over the course of this study. We identified decreased operative time, intra-operative blood loss, frequency of complications, and lengths of intensive care unit and hospital stay as the program matured. Through coordinated actions of the surgical and anesthesia teams, all intraoperative injuries were responded to in an effective, emergent fashion and all but one patient was saved. This resulted in an inhospital and 30-day mortality rate of only 0.5%.
Our study suggests that a dual attending approach, focus on avoiding “failure to rescue”, increased volume, and a surgeon driven commitment to quality improvement may lead to low mortality rates after transhiatal esophagectomy.
PMCID: PMC4279687  PMID: 25550708
Esophagectomy; Esophageal cancer; Failure to rescue; Outcome-volume relationships; Quality improvement; Postoperative complication
6.  The vascular connector, design of a new device for sutureless vascular anastomosis 
In recent years, several methods and new techniques have been studied and proposed for establishment of sutureless vascular anastomoses, streaming use of sutureless vascular surgery in the future.
Presentation of the hypothesis
The new vascular connector (NVC) is a hypothetical design of a vascular device, proposed for creation and maintenance of sutureless vascular anastomosis. Implication of NVC would introduce a new device and technique in establishment of sutureless vascular anastomosis in which surgical approach is minimized and so post-operation disorders. It would eliminate need for suture; shorten clampage and operation time, consequently reducing stress for both, the surgeon and the patient. It enables the creation of vascular anastomosis fast, simple, safe, reliable, with satisfactory patency and stability of anastomosis.
Testing the hypothesis
Efficacy of NVC needs to be evaluated in further studies, in order to be confirmed for clinical use. The effectiveness of NVC should be verified firstly in vitro and in vivo tests; and by animal experiments. The likelihood of its negative influence in thrombogenicity should be well evaluated.
Implications of the hypothesis
Implication of the new vascular connector (NVC) would be of interest to both patients and the surgeon due to the following main achievements: 1) enables the creation of vascular anastomosis fast and simple, 2) significant shortening of clampage time of blood vessels and operation time-this assumption would be followed by reduced risk of operative and post-operative complications and length of hospital stay or admission to Intensive care unit, 3) safe and reliable, 4) compatible with any blood vessel and standard vascular graft, 5) using the NVC we will reduce in minimum need for replaced blood volume, 6) reduces the cost of treatment. It is anticipated that the NVC would provide shorter operation time and least operative and post-operative complications in creation of sutureless vascular anastomosis.
PMCID: PMC4260208  PMID: 25493096
Sutureless vascular anastomosis; New vascular connector; Vessel circuits
7.  Fluorescent imaging of the biliary tract during laparoscopic cholecystectomy 
The introduction of laparoscopic cholecystectomy was associated with increased incidences of bile duct injury. The primary cause appears to be misidentification of the biliary anatomy. Routine intra-operative cholangiography has been recommended to reduce accidental duct injury, although in practice it is more often reserved for selected cases. There has been interest in the use of fluorescent agents excreted via the biliary system to enable real-time intra-operative imaging, to aid the laparoscopic surgeon in correctly interpreting the anatomy. The primary aim of this review is to evaluate the ability of fluorescent cholangiography to identify important biliary anatomy intra-operatively. Secondary aims are to investigate its ability to detect important intra-operative pathology such as bile leaks, identify potential alternative fluorophores, and evaluate the evidence regarding patient outcomes.
PMCID: PMC4196113  PMID: 25317203
Fluorescent cholangiography; Laparoscopic cholecystectomy; Intraoperative cholangiography; Imaging; Fluorophore
8.  Emergency primary repair of grade V bladder neck injury complicating pelvic fracture 
We report a case of a grade V bladder injury complicating an open-book pelvic fracture following a road traffic accident. The bladder neck injury was primarily repaired in the emergency setting of a poor-resourced area with successful outcome. The dangers of urinary extravasation are still to be considered of importance and we advocate and encourage immediate/emergency open intervention although it remains controversial to say the least in a lesser resourced healthcare set up.
PMCID: PMC4115162  PMID: 25076980
Pelvic injury; Bladder neck injury; Extravasation; Primary repair; Scrotal necrotizing fasciitis
9.  A preliminary investigation of anti-reflux intervention for gastroesophageal reflux related childhood-to-adult persistent asthma 
Childhood-to-adult persistent asthma is usually considered to be an atopic disease. However gastroesophageal reflux may also play an important role in this phenotype of asthma, especially when it is refractory to pulmonary medicine.
Fifty-seven consecutive GERD patients who had decades of childhood-to-adult persistent asthmatic symptoms refractory to pulmonary medication were enrolled. GERD was assessed by a symptom questionnaire, endoscopy, reflux monitoring, and manometry, and treated by Stretta radiofrequency (SRF) or laparoscopic Nissen fundoplication (LNF). The outcomes were followed up with a questionnaire for an average of 3.3 ± 1.1 years.
Upper esophageal sphincter hypotonia, lower esophageal sphincter (LES) hypotonia, shortened LES, and esophageal body dyskinesia were demonstrated by esophagus manometry in 50.9%, 43.9%, 35.1%, and 45.6% of the patients, respectively. The symptom scores for heartburn, regurgitation, coughing, wheezing, and chest tightness significantly decreased from 5.8 ± 2.0, 5.6 ± 2.0, 7.3 ± 1.6, 8.4 ± 1.2, and 8.1 ± 1.5, to 1.2 ± 1.8, 1.1 ± 1.6, 2.8 ± 2.5, 3.8 ± 2.7, and 3.9 ± 2.7, respectively, after anti-reflux treatment (P < 0.001).
Esophagus dysfunction is high in childhood-to-adult persistent asthmatic patients with GERD. SRF and LNF are both effective for esophagus symptoms as well as persistent asthmatic symptoms for these patients. GER may relate with asthmatic symptoms in some patients. Evaluating asthmatic patients for possible treatment of the underlying cause, such as GERD, may improve symptoms and prevent disease persistence.
PMCID: PMC4077581  PMID: 24987453
Asthma; Gastroesophageal reflux; Stretta radiofrequency; Laparoscopic nissen fundoplication
10.  Sentinel lymph node biopsy in esophageal cancer: an essential step towards individualized care 
Lymph node status is the most important prognostic factor in esophageal cancer. Through improved detection of lymph node metastases, using the sentinel lymph node concept, accurate staging and more tailored therapy may be achieved. This review article outlines two principle ways in which the sentinel lymph node concept could dramatically influence current standard of care for patients with esophageal cancer. We discuss three limitations to universal acceptance of the technique, and propose next steps for increasing enthusiasm amongst physicians and surgeons including the development of a universal tracer, and improved contrast agents with novel dual-modality ‘visibility’.
PMCID: PMC4019891  PMID: 24829610
Sentinel lymph node; Esophageal cancer; Micrometastasis; Isolated tumor cell; Endoscopic mucosal resection
11.  Female urethral diverticulum: cases report and literature 
A female urethral diverticulum is an uncommon pathologic entity. It can manifest with a variety of symptoms involving the lower urinary tract. Our objective is to describe the various aspects of the diverticulum of the female urethra such as etiology, diagnosis and treatment.
Cases presentation
We report five female patients, without prior medical history. They had different symptoms: dysuria in four cases, recurrent urinary tract infection in three cases, stress incontinence in two cases and hematuria in two cases. All patients had dyspareunia. The physical exams found renitent mass located in the endovaginal side of urethra which drained pus in two cases. Urethrocystography found a diverticulum of urethra in all cases. Our five patients underwent diverticulotomy by endovaginal approach. The course after surgical treatment was favorable. The urinary catheter was withdrawn after ten days. Some recurrent symptoms were reported.
Evaluation of recurrent urinary complaints in young women can lead to the finding of a diverticulum of urethra. Urethrocystography can reveal this entity. Diverticulectomy by endovaginal approach is the best choice for treatment.
PMCID: PMC3930819  PMID: 24528809
Urethra; Diverticulum; Woman; Diverticulectomy; Endovaginal approach
12.  Rationale, bench testing and in vivo evaluation of a novel 5 mm laparoscopic vessel sealing device with homogeneous pressure distribution in long instrument jaws 
In 1998, an electrothermal bipolar vessel sealing (EBVS) system was introduced and quickly became an integral component of the surgical armamentarium in various surgical specialties. Currently available EBVS instruments use a scissor-like jaw configuration and closing mechanism, which causes decreasing compression pressure from the proximal to the distal end of the jaws. A new EBVS system is described here which utilizes a different instrument jaw configuration and closing mechanism to enable a more homogeneous pressure distribution despite longer instrument jaws.
Results of jaw pressure distribution measurements as well as sealing experiments with subsequent burst pressure measurements ex vivo on bovine uterine arteries are demonstrated. Furthermore, an in vivo evaluation of the new EBVS system in a canine and porcine model including histological examination is presented.
The device revealed an even pressure distribution throughout the whole jaw length. The ex vivo burst pressure measurements revealed high average burst pressures, above 300 mmHg, independent of the outer diameter (1 to 7 mm) of the tested vessels. Histological evaluation of sealed vessels 21 days postoperatively demonstrated sealed and fused vessels without adjacent tissue damage.
The even pressure distribution leading to a sufficient tissue sealing in combination with the novel closing mechanism and extended jaw length differentiates the novel device from other available EBVS systems. This might offer a reduction of the overall procedure time, which should be further evaluated in a clinical study.
PMCID: PMC4029388  PMID: 24325831
Surgical instruments; Tissue sealing; Laparoscopic surgery; Hemostasis; Electrocoagulation; Electrosurgery; Thermal injury; Burst pressure; Equipment design
13.  Open versus minimally invasive sacroiliac joint fusion: a multi-center comparison of perioperative measures and clinical outcomes 
Sacroiliac (SI) joint pain is an under diagnosed source of low back pain due in part to lack of visible pathology on radiographs and symptoms mimicking other back-related disorders. Open SI joint fusion has been performed since the 1920s. This technique has fallen out of favor with the introduction of minimally invasive options. To date there has been no direct comparison between open and MIS SI joint fusion.
We conducted a multi-center, retrospective comparative cohort study of patients who underwent SI joint fusion using either an open surgical (OS) technique using a combination of screws and cages or a minimally invasive surgical (MIS) technique with a series of titanium plasma spray (TPS) coated triangular implants. Operative measures including surgical operating time, length of hospitalization and estimated blood loss (EBL) were collected along with demographics and medical history, surgical complications, and 12- and 24-month pain scores. Improvements in pain were compared after matching for age and gender and controlling for a history of lumbar spine fusion using repeated measures analysis of variance.
Data were available for 263 patients treated by 7 surgeons; 149 patients treated with OS and 114 treated with MIS SI joint fusion. Compared to OS patients, MIS patients were on average 10 years older (mean age 57 vs. 46) and 69% of all patients were female. MIS operative measures of EBL, operating time and length of hospitalization were significantly lower than open surgery (p < 0.001). Pain relief, measured as change from baseline to 12 months in VAS pain rating, was 3.5 points lower in the MIS vs. OS group (-6.2 vs. -2.7 points, p < 0.001). When matched for age, gender and a history of prior lumbar spinal fusion, postoperative pain scores were on average 3.0 points (95% CI 2.1 – 4.0) lower in MIS vs. OS (rANOVA p < 0.001).
In this multi-center comparative study, patients who underwent either OS or MIS SI joint fusion showed postoperative improvements in pain score. Compared to OS patients, patients who underwent MIS SI joint fusion had significantly greater pain relief and more favorable perioperative surgical measures.
PMCID: PMC3817574  PMID: 24172188
Minimally invasive surgery; Sacroiliac joint; Arthrodesis; Open surgery
14.  Low COST surgery setting for one-operational port laparoscopic hysterectomy surgery with ordinary laparoscopic instruments: preliminary results 
Hysterectomy dates back to 120BC and is the second most commonly performed gynecological surgery in the world. Cosmetic demands and the necessity of rapid return to work have contributed to the minimally invasive laparoscopic approach for hysterectomy. The majority of reports describe the use of three or four incisions to perform the surgery (two or three for manipulation and one for optics).
This work describes our experience with using only two ports for 11 patients who underwent video-laparoscopic hysterectomy surgery. One port was used for the optical system, and the second was used for manipulation. Early and late surgery complications, as well as the time to return to work and daily activities, were assessed.
The mean age of the patients was 41.4 years old (range 16 to 52 years) and the mean uterine weight was 133.54 g, ranging from 35 g and 291 g. The operative time ranged from 30 to 60 minutes (average 46.4 minutes) and the hospital stay ranged between 24 and 48 hrs. No intraoperative complications occurred, and no early or late postoperative complications were recorded. Patients reported minimal pain during the first 24–48 hrs in the hospital. Patients returned to their daily activities within seven days after surgery. Clinical care follow-up continued until the 40th postoperative day.
The laparoscopic hysterectomy technique with a single port for manipulation is a feasible procedure when the uterine weight is not greater than 400 mg with little postoperative pain. The patients had an early return-to-work and daily activities and a better cosmetic outcome. These preliminary data led us to make the one-operative port laparoscopic hysterectomy the procedure of choice for patients with a low uterine weight.
PMCID: PMC3852997  PMID: 24088385
Videolaparoscopy; Hysterectomy; Single port
15.  Minimally invasive sacroiliac joint fusion: one-year outcomes in 18 patients 
Sacroiliac joint (SI) pain is an often-overlooked cause of low back pain due, in part, to lack of specific findings on radiographs and symptoms mimicking other back-related disorders. We report our experience with minimally invasive (MIS) SI joint arthrodesis using a series of triangular, titanium plasma spray (TPS) coated implants in patients refractory to conservative care.
We report outcomes from 18 patients with 12 months of postoperative follow-up.
Demographics, complications, and clinical outcomes using visual analog scale (VAS) for pain, Oswestry Disability Index (ODI) for back function and SF-12 for quality of life were collected preoperatively and at 3, 6 and 12 months post-operatively.
Mean age was 64 years and 67% of patients were female. There were no intraoperative complications and one explant at three months for malposition.
All patient-reported outcomes showed both clinically and statistically significant improvement at 12 months (p < 0.001 for each of the following): VAS improved by 6.6 points, ODI scores improved by −37.5 points. One year SF-12 physical and mental component (PCS, MCS) scores approximated population normal scores for both physical and mental functioning. Patient satisfaction with outcomes was high at 95%; 89% said would have the same surgery again.
MIS SI joint fusion using a series of triangular porous TPS coated titanium implants is a safe and effective procedure for patients with SI joint disorders who have failed conservative care.
PMCID: PMC3852345  PMID: 24040944
Minimally invasive surgery; Sacroiliac joint; Arthrodesis; Previous spine surgery
16.  Atraumatic Flexor tendon retrieval- a simple method 
Zone 2 flexor tendon injuries still represent a challenging problem to hand surgeons despite the well developed surgical techniques and suture materials. Meticulous surgical repair with atraumatic handling of the severed tendon stumps and minimal damage to the tendon sheath are particularly important to prevent postoperative adhesions and ruptures in this area.
In zone 2 flexor tendon injuries proximal to the vinculas, the cut ends of the flexor tendons retract to the palm with muscle contraction. To retrieve the severed proximal flexor tendon under tendon sheath and pulley system is very difficult without damaging these structures. Many techniques are described in the literature for the delivery of the retracted proximal tendon stump to the repair site.
In this report we would like to present a simple and relatively atraumatic technique that facilitates passing of the retracted flexor tendon through the pulleys in zone 2. We sutured the proximal tendon stump at the distal palmar crease with 3–0 polypropylene suture and used a 14 gauge plastic feeding tube, acting like a conduit for the passage of straightened needle to the finger.
We have used this technique 21 times without any complication in our clinic. We have not seen any suture breakage during the passage or needle breakage due to the bending of the needle.
We have found this technique is very simple and very effective in retrieving the retracted tendon stump without causing undue damage to the tendon stump or tendon sheath.
PMCID: PMC3852352  PMID: 24040913
Flexor tendon retrieval; Atraumatic flexor tendon retrieval; Tendon retrieval; Retracted flexor tendon
17.  Device-tissue interactions: a collaborative communications system 
Medical devices, including surgical staplers, energy-based devices, and access enabling devices, are used routinely today in the majority of surgical procedures. Although these technically advanced devices have proved to be of immense benefit to both surgeons and patients, their rapid development and continuous improvement have had the unintended consequence of creating a knowledge gap for surgeons due to a lack of adequate training and educational programs. Thus, there is an unmet need in the surgical community to collect existing data on device-tissue interactions and subsequently develop research and educational programs to fill this gap in surgical training. Gathering data and developing these new programs will require collaboration between doctors, engineers, and scientists, from both clinical practice and industry. This paper presents a communications system to enable this unique collaboration that can potentially result in significantly improved patient care.
PMCID: PMC3737119  PMID: 23895104
Access-enabling device; Education; Energy device; Patient outcome; Stapler; Surgeon; Tissue
18.  Potential of the SPY intraoperative perfusion assessment system to reduce ischemic complications in immediate postmastectomy breast reconstruction 
The quality and viability of mastectomy flaps remain a central challenge in reconstructive surgery, particularly for immediate breast reconstruction. Insufficient perfusion in tissue flaps is a leading cause of early complications following reconstructive procedures, and clinical judgment alone is not completely reliable for the assessment of flap viability. Accurate and reliable intraoperative methods for assessment of tissue perfusion are needed to help surgeons identify tissue at risk for ischemia and necrosis, thereby allowing for maneuvers to improve tissue flap viability.
This study evaluates the use of intraoperative laser angiography using the SPY System (LifeCell Corp., Branchburg, NJ) for the assessment of perfusion in mastectomy flaps for immediate breast reconstruction. The SPY System uses the contrast agent indocyanine green, which has an excellent safety profile and pharmacokinetics that allow for repeat evaluations during the same surgical procedure. In recent work, the SPY System has demonstrated high sensitivity and specificity for detection of tissues at risk for ischemia and necrosis during reconstructive surgery. Using a retrospective, chart-review design, the authors compared consecutive cases of immediate breast reconstruction using a prosthesis, before and after implementation of the SPY System.
Ninety-one subjects were included in the analysis: 52 prior to SPY (Pre-SPY) and 39 after implementation of SPY (Post-SPY). Baseline characteristics were similar between the groups. Both groups had high rates of comorbidities, chemotherapy, and radiation therapy. The rate of postoperative complications was two-fold higher in the Pre-SPY group compared to the Post-SPY group (36.5% vs. 17.9%); this difference was of borderline significance (P = 0.0631). However, mean number of repeat visits to the OR per patient was significantly higher in the Pre-SPY group (1.21 ± 1.47 vs. 0.41 ± 0.71; P = 0.0023). Of the seven patients with complications in the Post-SPY group, five were identified by SPY as having poor flap perfusion; none were identified by clinical judgment alone.
This study suggests that the SPY System can contribute to reduced ischemia-related complications in a population of women undergoing immediate breast reconstruction following mastectomy for breast cancer.
PMCID: PMC3733811  PMID: 23875697
19.  Giant fibroepithelial stromal polyp of the vulva: largest case reported 
Fibroepithelial stromal polyps are site-specific mesenchymal lesions that are commonly found in the vulvovaginal region in premenopausal females. These polyps usually are less than 5 cm in diameter and are most commonly identified during routine gynecological examination. Although the stromal polyp is benign, its differential diagnosis includes some malignant vulva lesions making it critical to ensure that an accurate pathologic diagnosis is made.
We present a case of a 21 year old female with a giant fibroepithelial stromal polyp of the vulva. Upon review of the literature this is the largest reported fibroepithelial stromal polyp to date.
Fibroepithelial stromal polyps can grow as large as 390 grams and can be 18.5-cm in diameter. Microscopic evaluation of the polyp is critical in the exclusion of malignancy with this diagnosis.
PMCID: PMC3716997  PMID: 23842282
20.  Vaccum drainage system application in the management of operation-related non-regional epidural hematoma 
Epidural intracranial hematoma is one of the most common complications of surgeries for intracranial tumors. The non-regional epidural hematoma is related to severe fluctuation of the intracranial pressure during the operation. The traditional management of hematoma evacuation through craniotomy is time-consuming and may aggravate intracranial pressure imbalance, which causes further complications. We designed a method using vaccum epidural drainage system, and tried to evaluate advantage and the disadvantage of this new technique.
Seven patients of intracranial tumors were selected. All of the patients received tumor resection and intra-operative non-regional epidural hematoma was confirmed through intra-operative ultrasound or CT scan. The vaccum drainage system was applied. Another ten patients who received craniotomy for intra-operative non-regional epidural hematoma evacuation were selected as comparison. Regular tests, like serial CT scan, were performed afterward to evaluate the effectiveness and to help deciding when to remove the drainage system.
The vaccum drainage method was effective in epidual hemotoma clearance and prevented recurrent epidural hemorrhage. The drainage systems were removed within 4 days. All of the patients recovered well. No complications related to the drainage system were observed.
Compared to the traditional craniotomy, the new method of epidural hemoatoma management using vaccum epidural drainage system proved to be as effective in hematoma clearance, and was less-invasive and easier to perform, with less complication, shorter hospitalization, less economic burden, and better prognosis.
PMCID: PMC3751531  PMID: 23842198
Intracranial tumor; Operation-related epidural hematoma; Non-regional epidural hematoma; Epidural drainage; Vaccum drainage system
21.  A rare case of Endometriosis in vaginal hysterectomy scar 
Presented hereunder is probably the first reported case of endometriosis at the vaginal apex following vaginal hysterectomy. No other similar case could be traced in the review of the literature.
PMCID: PMC3707828  PMID: 23816336
Endometriosis; Vaginal Hysterectomy; Vault
22.  Modified Quad surgery significantly improves the median nerve conduction and functional outcomes in obstetric brachial plexus nerve injury 
Nerve conduction studies or somatosensory evoked potentials (SSEPs) have become an important tool in the investigation of peripheral nerve lesions, and is sensitive in detecting brachial plexus nerve injury, and other nerve injuries.
To investigate whether the modified Quad surgical procedure improves nerve conductivity and functional outcomes in obstetric brachial plexus nerve injury (OBPI) patients.
All nerves were tested with direct functional electrical stimulation. A Prass probe was used to stimulate the nerves, and recording the response, the compound motor action potential (CMAP) in the muscle. SSEP monitoring was performed pre- and post modified Quad surgery, stimulating the median and ulnar nerves at the wrist, the radial nerve over the dorsum of the hand, recording the peripheral, cervical and cortical responses. All patients have had the modified Quad surgery (n = 19). The modified Quad surgery is a muscle release and transfer surgery with nerve decompressions. All patients were assessed preoperatively and postoperatively by evaluating video recordings of standardized movements, the modified Mallet scale to index active shoulder movements.
The cervical responses were significantly lower in amplitude in the affected arm than the un-affected arm. The median nerve conduction was significantly improved from 8.04 to 9.26 (P < 0.022) post-operatively. The shoulder abduction was also significantly improved (pre-op 30° ± 23.3 to 143° ± 33.7, p < 0.0001), with a mean follow-up of 43 months after the modified Quad surgery in these patients.
Median nerve conduction, and shoulder abduction were significantly improved in OBPI children, who have undergone the modified Quad procedure with neuroplasty, internal microneurolysis and tetanic stimulation of the median nerve.
PMCID: PMC3668219  PMID: 23714699
Obstetric brachial plexus nerve injury; Electromyography; Nerve conduction study; Somatosensory evoked potentials; Shoulder abduction; Modified Quad surgery
23.  Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review 
Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.
PMCID: PMC3637616  PMID: 23587203
24.  Expandable Micro-motor Bur, design of a new device for least invasive extraction of broken teeth roots 
Extraction of a broken tooth root is often a traumatic experience for both the practitioner and the patient. To extract broken roots, generally invasive approaches as open window surgeries or mucoperiosteal flap and/or removal of buccal bone are performed.
Presentation of the hypothesis
Expandable micro-motor bur (EMB) is a hypothetical design of a dental instrument proposed for removal of broken teeth roots that cannot be extracted by the routine closed methods and in which common instrumentations cannot afford to accomplish. Implication of EMB would introduce a new technique in removal of broken teeth roots in which surgical trauma is minimized and so post-extraction disorders. It would eliminate surgical invasion to the surrounding tissues; and also it would eliminate profound hand forces by the practitioner, consequently reduces stress for both the practitioner and the patient. It would eliminate high risk aftermaths such as operative morbidity (due to bone loss), maxillary sinus exposure and probable need for additional surgery as are indicative of some conventional open access approaches.
Testing the hypothesis
Further studies are needed to confirm its effect in clinical cases. The effectiveness of EMB should be verified firstly by animal experiments. The likelihood of its negative influence on nearby vascular and nerve system should be well evaluated.
Implications of the hypothesis
Implication of EMB would be of interest to both patients and the surgeon due to the following main achievements: a) no need for mucoperiosteal flap, hence preservation of soft tissue, b) no need for osteotomy, hence retention of buccal bone, c) less risk of sinus exposure, d) minimum chance of post operative infections due to eliminated surgeries in soft tissues and bones and e) in terms of esthetics, it will have a special meaning for immediate placement of dental implants. EMB’s structural components include Bur head, Spacers and Bur base. A micro motor would power its spin. In contrast to conventional surgical approaches, EMB procedure is conservative. It is anticipated that EMB would provide less traumatic and least post-operative complications in extraction of broken teeth roots.
PMCID: PMC3641986  PMID: 23497515
Tooth extraction; Complicated root extraction; Expandable micro-motor bur; EMB
25.  Outcome of repeat surgery for genital prolapse using prolift-mesh 
Urogenital prolapse can have a significant impact on quality of life. The life time risk of requiring surgery for urogenital prolapse is 11%. Prolift mesh has recently been introduced to reduce repeat operation rate and for long-term benefit.
To evaluate the outcome of the treatment of urogenital prolapse with synthetic mesh.
A retrospective review of case notes of all women who underwent prolift mesh insertion for prolapse between July 2004 and June 2005, at Royal Alexandra Hospital Paisley UK. We looked at the presenting complaints, previous operation, intraoperative complications and complications at six weeks and six months follow-up.
Twenty-two procedures were carried out in the twelve months period. Age of the patients ranged from 55 to 82 years (median 64 yrs). Eleven had anterior Prolift (50%), Seven had posterior Prolift 31.8% and four total Prolift 18%. There were no intraoperative complications. All the patients had previous surgery for prolapse. Eight patients had anterior repair, six patients had posterior repair, and three patients had abdominal hysterectomy. Vaginal hysterectomy was carried out with mesh insertion as a concomitant procedure in seven cases (31.25%). All patients were seen at six weeks and six months after the surgery. Complications rate included mesh erosion one patient and suture material protruding in the vagina one patient, one patient had failed prolift operation. All the twenty-one patients were cured giving 95.4% success rate.
The use of prolene mesh in pelvic reconstructive surgery was associated with good outcome and minimal complications in this study.
PMCID: PMC3694470  PMID: 23497532
Prolift; Mesh; Urogenital prolapse

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