Comparison of Surgical Freedom and Area of Exposure in Three Endoscopic Transmaxillary Approaches to the Anterolateral Cranial Base

Objective Endoscopic ipsilateral endonasal transmaxillary, contralateral endonasal transseptal transmaxillary, and Caldwell-Luc approaches can access lesions within the retromaxillary space and pterygopalatine fossa. We compared the exposure and surgical freedom of these transmaxillary approaches to assist with surgical decision making. Design Four cadaveric heads were dissected bilaterally using the three approaches just described. Prior to dissection, stereotactic computed tomography (CT) scans were obtained on each head to obtain anatomical measurements. Surgical freedom and area of exposure were determined by stereotaxis. Main Outcome Measures Area of exposure was calculated as the extent of the orbital floor, maxillary sinus floor, nasal floor, and mandibular ramus exposed through each approach. Surgical freedom was the area through which the proximal end of the endoscope could be freely moved while moving the tip of the endoscope to the edges of the exposed area. Results The mean exposed area was similar: 9.9 ± 2.5 cm² (Caldwell-Luc), 10.4 ± 2.6 cm² (ipsilateral endonasal), and 10.1 ± 2.1 cm² (contralateral transseptal) (p > 0.05). The surgical freedom of the Caldwell-Luc approach (113 ± 7 cm²) was greater than for either endonasal approach, 76 cm²± 15 (p = 0.001) (ipsilateral endonasal) and 83 cm² ± 15 (p = 0.003) contralateral transseptal. Conclusions Our work demonstrates that the Caldwell-Luc endonasal approach offers greater surgical freedom than either approach for anterolateral skull base targets, although these approaches offer similar exposure.     

内镜和显微镜下经鼻入路鞍区的解剖学对比研究

目的 研究对比神经内镜和手术显微镜经单鼻孔鼻内-蝶窦入路的解剖特点,为临床应用提供解剖学理论依据.方法 福尔马林浸泡固定的尸头10例,彩色乳胶灌注动脉系统.模拟经鼻内入路鞍区手术,先用显微镜,然后更换为内镜观察并测量相关解剖结构.结果 内镜相比显微镜:在蝶鞍水平区域,鞍旁术野同侧和对侧分别增加平均5.0 mm和6.5 mm的显露范围;前颅底区域,矢状位增加4.0 mm,横向同侧、对侧增加3.5 mm、4.0 mm;斜坡后颅底区域,都能显露对侧的斜坡旁颈内动脉隆起,而向两侧观察,内镜的显露范围平均同侧增加4.0 mm,对侧2.5 mm.结论 内镜可以提供一种全景的术野,从而扩展了经鼻入路显微手术的显露范围,尤其适用于简化和扩大经鼻内八路鞍区手术.     

内镜和显微镜下经鼻入路鞍区的解剖学对比研究

目的 研究对比神经内镜和手术显微镜经单鼻孔鼻内-蝶窦入路的解剖特点,为临床应用提供解剖学理论依据.方法 福尔马林浸泡固定的尸头10例,彩色乳胶灌注动脉系统.模拟经鼻内入路鞍区手术,先用显微镜,然后更换为内镜观察并测量相关解剖结构.结果 内镜相比显微镜:在蝶鞍水平区域,鞍旁术野同侧和对侧分别增加平均5.0 mm和6.5 mm的显露范围;前颅底区域,矢状位增加4.0 mm,横向同侧、对侧增加3.5 mm、4.0 mm;斜坡后颅底区域,都能显露对侧的斜坡旁颈内动脉隆起,而向两侧观察,内镜的显露范围平均同侧增加4.0 mm,对侧2.5 mm.结论 内镜可以提供一种全景的术野,从而扩展了经鼻入路显微手术的显露范围,尤其适用于简化和扩大经鼻内八路鞍区手术.     

内镜和显微镜下经鼻入路鞍区的解剖学对比研究

目的 研究对比神经内镜和手术显微镜经单鼻孔鼻内-蝶窦入路的解剖特点,为临床应用提供解剖学理论依据.方法 福尔马林浸泡固定的尸头10例,彩色乳胶灌注动脉系统.模拟经鼻内入路鞍区手术,先用显微镜,然后更换为内镜观察并测量相关解剖结构.结果 内镜相比显微镜:在蝶鞍水平区域,鞍旁术野同侧和对侧分别增加平均5.0 mm和6.5 mm的显露范围;前颅底区域,矢状位增加4.0 mm,横向同侧、对侧增加3.5 mm、4.0 mm;斜坡后颅底区域,都能显露对侧的斜坡旁颈内动脉隆起,而向两侧观察,内镜的显露范围平均同侧增加4.0 mm,对侧2.5 mm.结论 内镜可以提供一种全景的术野,从而扩展了经鼻入路显微手术的显露范围,尤其适用于简化和扩大经鼻内八路鞍区手术.     

Is the Combination of Convex Compression for the Proximal Thoracic Curve and Concave Distraction for the Main Thoracic Curve Using Separate-rod Derotation Effective for Correcting Shoulder Balance and Thoracic Kyphosis?

BackgroundPosterior correction of the proximal thoracic curve in patients with adolescent idiopathic scoliosis has been recommended to achieve shoulder balance. However, finding a good surgical method is challenging because of the small pedicle diameters on the concave side of the proximal thoracic curve. If the shoulder height can be corrected using screws on the convex side, this would appear to be a more feasible approach.Questions/purposesIn patients with adolescent idiopathic scoliosis, we asked: (1) Is convex compression with separate-rod derotation effective for correcting the proximal thoracic curve, shoulder balance, and thoracic kyphosis? (2) Which vertebrum is most appropriate to serve as the uppermost-instrumented vertebra? (3) Is correction of the proximal thoracic curve related to the postoperative shoulder balance?MethodsBetween 2015 and 2017, we treated 672 patients with scoliosis. Of those, we considered patients with elevated left shoulder, Lenke Type 2 or 4, or King Type V idiopathic scoliosis as potentially eligible. Based on that, 17% (111 of 672) were eligible; 5% (6 of 111) were excluded because of other previous operations and left-side main thoracic curve, 22% (24 of 111) were excluded because they did not undergo surgery for the proximal thoracic curve with only pedicle screws, 21% (23 of 111) were excluded because the proximal thoracic curve was not corrected by convex compression and separate rod derotation, and another 3% (3 of 111) were lost before the minimum study follow-up of 2 years, leaving 50% (55 of 111) for analysis. During the study period, we generally chose T2 as the uppermost level instrumented when the apex was above T4, or T3 when the apex was T5. Apart from the uppermost-instrumented level, the groups did not differ in measurable ways such as age, sex, Cobb angles of proximal and main thoracic curves, and T1 tilt. However, shoulder balance was better in the T3 group preoperatively. The median (range) age at the time of surgery was 15 years (12 to 19 years). The median follow-up duration was 26 months (24 to 52 months). Whole-spine standing posteroanterior and lateral views were used to evaluate the improvement of radiologic parameters at the most recent follow-up and to compare the radiologic parameters between the uppermost-instrumented T2 (37 patients) and T3 (18 patients) vertebra groups. Finally, we analyzed radiologic factors related to shoulder balance, defined as the difference between the horizontal lines passing both superolateral tips of the clavicles (right-shoulder-up was positive), at the most recent follow-up.ResultsConvex compression with separate-rod derotation effectively corrected the proximal thoracic curve (41° ± 11° versus 17° ± 10°, mean difference 25° [95% CI 22° to 27°]; p < 0.001), and the most recent shoulder balance changed to right-shoulder-down compared with preoperative right-shoulder-up (8 ± 11 mm versus -8 ± 10 mm, mean difference 16 mm [95% CI 12 to 19]; p < 0.001). Proximal thoracic kyphosis decreased (13° ± 7° versus 11° ± 6°, mean difference 2° [95% CI 0° to 3°]; p = 0.02), while mid-thoracic kyphosis increased (12° ± 8° versus 18° ± 6°, mean difference -7° [95% CI -9° to -4°]; p < 0.001). Preoperative radiographic parameters did not differ between the groups, except for shoulder balance, which tended to be more right-shoulder-up in the T2 group (11 ± 10 mm versus 1 ± 11 mm, mean difference 10 mm [95% CI 4 to 16]; p = 0.002). At the most recent follow-up, the correction proportion of the proximal thoracic curve was better in the T2 group than the T3 group (67% ± 10% versus 49% ± 22%, mean difference 19% [95% CI 8% to 30%]; p < 0.001). In the T2 group, T1 tilt (6° ± 4° versus 6° ± 4°, mean difference 1° [95% CI 0° to 2°]; p = 0.045) and shoulder balance (-14 ± 11 mm versus -7 ± 9 mm, mean difference -7 mm [95% CI -11 to -3]; p = 0.002) at the most recent follow-up improved compared with those at the first erect radiograph. The most recent shoulder balance was correlated with the correction proportion of the proximal thoracic curve (r = 0.29 [95% CI 0.02 to 0.34]; p = 0.03) and change in T1 tilt (r = 0.35 [95% CI 0.20 to 1.31]; p = 0.009).ConclusionUsing the combination of convex compression and concave distraction with separate-rod derotation is an effective method to correct proximal and main thoracic curves, with reliable achievement of postoperative thoracic kyphosis and shoulder balance. T2 was a more appropriate uppermost-instrumented vertebra than T3, providing better correction of the proximal thoracic curve and T1 tilt. Additionally, spontaneous improvement in T1 tilt and shoulder balance is expected with upper-instrumented T2 vertebrae. Preoperatively, surgeons should evaluate shoulder balance because right-shoulder-down can occur after surgery in patients with a proximal thoracic curve.Level of EvidenceLevel III, therapeutic study.     

Cervical pedicle screw fixation at C6 and C7: A cadaveric study

Background:Cervical pedicle screw fixation is an effective method for treating traumatic and non traumatic injuries. But many studies have reported higher incidence of cervical pedicle penetration, so many research efforts have aimed at improving the accuracy of cervical screw fixation. Most of the anatomical studies on cervical pedicle screw placement previously published focused on the measurements of anatomical parameters, the entry point of pedicle screw is vague. We preliminarily designed a C3, C4 and C5 pedicle screw fixation method that had clear entry point and clinical cases confirmed that this method is feasible and safe. So we did this study of cervical pedicle screw fixation for C6 and C7 vertebrae.Results:In C6, the PW and PH were 6.12 ± 0.78 and 7.48 ± 0.81 mm, respectively. In C7, the PW and PH were 6.85 ± 0.73 and 8.03 ± 0.38 mm, respectively. The LSC was 30.83 ± 0.91 mm. Two E angles were identified, namely E1 and E2 and their values were 89.61 ± 1.24 and 59.71 ± 1.10°, respectively. Meanwhile, F averaged 75.86 ± 1.12°.Conclusion:The intersection of the horizontal line through the midpoint of the transverse process root and vertical line through the intersection of the posterolateral and posterior planes of the isthmus can be used as an entry point for C6 and C7 pedicle screw fixation. The screws should be inserted at 60 or 90° with the posterolateral isthmus in the horizontal plane and at 75° with the posterior isthmus in the sagittal plane. The LSC should not exceed 30 mm.     

Comparison between the microscope and endoscope in the direct endonasal extended transsphenoidal approach: anatomical study

OBJECT: The authors compare the views afforded by the operating microscope and the endoscope in the direct endonasal extended transsphenoidal approach to the sellar, suprasellar, and parasellar regions. METHODS: Five formalin-fixed, silicone-injected adult cadaveric heads were studied. A direct endonasal transsphenoidal approach was performed via the right nostril, pushing aside the nasal septum. The approach was performed with the microscope first, then with the endoscope. For each step (sellar, suprasellar, and clival), the exposure afforded by direct microscopic view was measured and then compared with that obtained using the endoscope. The direct endonasal approach provides a slightly off-midline view. Although the microscope provides an adequate view of the midline structures and part of the contralateral parasellar areas, the addition of the endoscope allows for a more panoramic view and permits widening of the approach in all directions. CONCLUSIONS: An adequate exposure of the sellar, suprasellar, and infrasellar/upper clival regions can be achieved via a simple, direct endonasal approach. From a direct endonasal route, there is a preferential visualization of the structures contralateral to the approach. The endoscope affords a more panoramic view that extends the area covered by the operating microscope.     

Practical and technical aspects of trans-sphenoidal surgery

Trans-sphenoidal surgery was first described more than a century ago. Today, this approach occupies a crucial place in the armamentarium of the neurosurgeon for the management of sellar, suprasellar, and parasellar pathological conditions. Over the years, the procedure has witnessed multiple modifications, benefitting from technological advances and from innovative ideas of pioneering neurosurgeons and otolaryngologists. The introduction of the microscope and then the endoscope allowed progressive improvement of visualization, illumination, and magnification in this restricted surgical corridor. With enhanced knowledge and understanding of the surgical anatomy of the skull base, the application of extended transsphenoidal approaches became possible, thus widening significantly the anatomical area that can be reached through this approach. In addition, the continuous improvement in imaging, image guidance, and microinstruments allowed better planning and precision during surgery. In sum, thanks to recent technological advance, trans-sphenoidal surgery can now be applied to a large area of the skull base and for a wide range of pathological conditions. With growing experience, the procedure is performed with enhanced safety and greater efficacy. In this paper, we review the historical evolution of trans-sphenoidal surgery and describe the modern applications and modifications of the procedure.     

Restoring Rotation Center in Total Hip Arthroplasty for Developmental Dysplasia of the Hip with the Assistance of Three Dimensional Printing Technology: A Pilot Study

ObjectiveTo develop a new method to restore hip rotation center exactly and rapidly in total hip arthroplasty (THA) with the assistance of three dimensional (3D) printing technology and evaluate its clinical and radiological outcomes.MethodsFrom March 2014 to July 2018, a total of 17 patients (five hips of four men and 16 hips of 13 women) with end‐stage osteoarthritis secondary to developmental dysplasia of the hip who underwent THA were analyzed and followed up retrospectively. The average age is 58.00 ± 8.12 years (range from 45 to 71 years). Simulated operations were performed on 3D printed hip models for preoperative planning. The morphology of Harris fossa and acetabular notches were recognized and restored to locate the acetabular center. The size of bone defect was measured by the bone wax method. The agreement on the size of acetabular cup and bone defect between simulated operations and actual operations were analyzed. Harris Hip Score (HHS) was used to evaluate the recovery of hip joint function. The vertical distance and horizontal distance of the rotation center on the pelvis plain radiograph were measured, which were used to assess the efficacy of restoring hip rotation center and acetabular cup migration.ResultsThe mean sizes of bone defect in simulated operations and THA were 4.58 ± 2.47 cm² and 4.55 ± 2.57 cm² respectively. There was no significant difference statistically between the sizes of bone defect in simulated operations and the actual sizes of bone defect in THA (t = 0.03, P = 0.97). The sizes of the acetabular cup of simulated operations on 3D print models showed a high rate of coincidence with the actual sizes in the operations (ICC = 0.93). All 17 patients were available for clinical and radiological follow‐up. The average follow‐up time was 18.35 ± 6.86 months (range, 12–36 months. The average HHS of the patients was improved from (38.33 ± 6.07) preoperatively to the last follow‐up (88.61 ± 3.44) postoperatively. The mean vertical and horizontal distances of hip rotation center on the pelvic radiographs were restored to 15.12 ± 1.25 mm and 32.49 ± 2.83 mm respectively. No case presented dislocation or radiological signs of loosening until last follow‐up.ConclusionsThe application of 3D printing technology facilitates orthopedists to recognize the morphology of Harris fossa and acetabular notches, locate the acetabular center and restore the hip rotation center rapidly and accurately.     

Detailed Anatomy for the Transoral Approach to the Craniovertebral Junction: An Exposure and Safety Study

Objective The aim of this study was to demonstrate the anatomical structures of the transoral approach to the craniovertebral junction. We evaluated the necessary exposure field and the safety of this approach. Methods Surgical operations with the transoral approach were performed on 36 cadaver specimens. The special anatomical structures were measured surrounding the exposure field with priorities given to measurements relating to the vertebral artery (VA). The anatomical relationships between the VA and nerves were observed. Results The exposure field partly covered the vertebral basilar system confluent. The middle clivus to upper C3 vertebral body can be exposed by transoral approach. Cranial nerves and cervical nerves emerged from the caudal of vertebrobasilar artery and circumambulated anterolaterally, and some abnormalities were observed in the intracranial segment of vertebrobasilar artery. The safe field was in an inverted trapezoid shape, of which the widest point was 25.5 ± 4.5 mm to the midline at C1 transverse process level; the narrowest point was 11.2 ± 1.5 mm to the midline at the C2–3 level. Conclusion Because the VA is the landmark of the safe field in this approach, surgeons should be very careful to avoid injuries of the VA and nerves while operating in the intracranial field or at the C2–3 level.     

围截骨区卫星棒技术在严重脊柱畸形三柱截骨术中的应用

 目的 探讨严重脊柱畸形三柱截骨术中围截骨区卫星棒技术的可行性,并评估其临床应用价值。方法 回顾性分析2012年7月至2014年1月期间应用卫星棒技术行严重脊柱畸形三柱截骨并有完整临床及影像学资料的13例患者,男6例,女7例;年龄12~57岁,平均（30.9±19.1）岁。分别测量患者手术前后及末次随访时侧凸Cobb角、最大后凸Cobb角（global kyphosis,GK）、冠状面平衡（distance between C₇ plumb line and center sacral vertical line,C₇PL-CSVL）和矢状面平衡（sagittal vertical axis,SVA）。患者初诊及每次随访均填写SF-36量表。结果 随访时间平均为（15.8±3.8）个月。术前侧凸Cobb角平均为86.3°±22.6°,术后为45.2°±19.7°,较术前明显改善,平均矫正率为47.7%±19.1%;末次随访为39.9°±19.8°,随访期间未见明显矫正丢失。术前GK为80.9°±18.7°,术后为35.1°±14.5°,平均矫正率为57.8%±13.8%;末次随访时未见明显丢失,平均为36.3°±10.0°。手术前后C₇PL-CSVL分别为（43.7±36.8） mm、（18.8±5.6） mm,术后有明显改善;末次随访时维持良好,平均为（19.2±8.3） mm。SVA由术前平均（55.0±51.5） mm减小至术后（29.3±19.5） mm,末次随访为（34.2±17.5） mm,亦无明显矫正丢失。13例患者术中监测均无信号异常。术后1例患者1枚螺钉位置偏上穿出上终板,1例患者1枚螺钉位置偏外。患者随访期间均无明显矫形丢失及断钉、断棒等内固定并发症。结论 严重脊柱畸形三柱截骨引入卫星棒技术既满足坚强固定需要又起到分散应力作用,术后矫形效果满意,随访期间矫正丢失及内固定失败等并发症少。     

Extradural Total Petrous Apex Resection With Trigeminal Translocation for Improved Exposure of the Posterior Cavernous Sinus and Petroclival Region

We have analyzed a strategy for improved exposure of the posterior cavernous sinus and petroclival region through an extradural subtemporal approach to be utilized in the removal of neoplastic processes with involvement of the apical petrous bone and posterior cavernous sinus. This surgical approach includes the following elements for improved exposure of the posterior cavernous sinus through the middle fossa corridor: (1) maximal extradural exposure and mobilization of the trigeminal nerve complex, allowing its elevation and anterior displacement, (2) complete extradural removal of the anterior petrous pyramid from the porus acousticus to the petrous apex under direct vision, (3) total exposure of the abducens nerve from the posterior fossa to its point of cross over the intracavernous carotid artery, and (4) wide extradural exposure of the cavernous carotid artery in the foramen lacerum region. This strategy can be combined with other related approaches; specifically, frontotemporal or posterior transpetrosal exposures for extensive lesions.

Microsurgical dissection and morphometric analysis were performed in 20 fixed cadaver specimens for the purposes of validating the method for clinical application and determining the key elements to maximization of exposure. The trigeminal complex could be anteromedially retracted 4.8 mm ± 1.3 (range = 3 to 6 mm) without skeletonization of V₂ and V₃. Liberating these two divisions from their bony canals to their first peripheral branch (10.4 mm ± 2.5 and 5.4 mm ± 1.1, respectively) resulted in increased mobilization an average of 9.1 mm ± 1.7 (7 to 14 mm). Further mobilization is achieved by dividing the attachment between the trigeminal connective tissue sheath and the fibrous carotid ring at the foramen lacerum. An average of 13.0 mm ± 3.1 (7 to 20 mm) of the posterior intracavernous carotid artery was exposed. Detailed microanatomic observations and a comprehensive morphometric analysis of the relevant anatomic relationships were made.

     

Needlescopic Surgery Versus Single-port Laparoscopy for Inguinal Hernia

Background and Objectives:

In recent years, 2 modifications of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair—needlescopic (nTAPP) surgery and single-port (sTAPP) surgery—have greatly improved patient outcomes over traditional approaches. For a comparison of these 2 modifications, we sought to investigate and compare the extent of surgical trauma and postoperative consequences for the abdominal wall in these two procedures.

Methods:

In a retrospective study, 50 nTAPP and 35 sTAPP procedures occurring at a community hospital from November 1, 2009, through July 31, 2012 were reviewed. Intraoperative data, including length of the umbilical skin incision and operative time, were recorded. A follow-up evaluation included investigation of hernia recurrence, postoperative pain, abdominal wall mobility, cosmetic satisfaction, and period of sick leave.

Results:

The mean umbilical skin incision was 13 ± 4 mm in nTAPP vs 27 ± 3 mm in sTAPP (P < .001). The nTAPP procedure required less operating time than the sTAPP procedure (54.8 ± 16.9 minutes vs 85.9 ± 19.7 minutes; P < .001). The mean immediate postoperative pain score on the visual analog scale was 2.7 ± 2.1 in the nTAPP group and 4.4 ± 1.9 in the sTAPP group (P = .016). In addition, patients who underwent nTAPP had a shorter period of sick leave (11.2 ± 8.4 days vs 24.1 ± 20.1 days; P = .02). At the follow-up evaluation after approximately 30 months, abdominal wall mobility and cosmetic satisfaction were equally positive, with no hernia recurrence.

Conclusion:

In patients with uncomplicated inguinal hernia, the nTAPP procedure, with less surgical trauma and operating time, has distinct advantages in reduction of immediate postoperative pain and sick leave time.     

Horizontal Rafting Plate for Treatment of the Tibial Plateau Fracture

ObjectiveThis study aimed to investigate the value of a horizontal rafting plate in treating tibial plateau fractures.MethodsThe data of 24 patients in whom a horizontal rafting plate was used to treat a tibial plateau fracture between October 2014 and January 2018 were retrospectively analyzed, including 16 males and 8 females, aged 21–63 years old, with an average of 40 ± 14.68 years. The fractures included 13 in the left knee and 11 in the right knee. The places where the horizontal rafting plate were used included the anterior margin of tibia, anterolateral tibia, and posterolateral tibia. All cases were followed up for 12–24 months, with an average follow‐up of 17.5 ± 5.0 months. At the last follow‐up, the Rasmussen radiological criteria were used to evaluate the effect of fracture reduction and fixation. The knee joint function was evaluated using the Rasmussen functional score. Computed tomography (CT) scanning and three‐dimensional reconstruction were performed preoperatively and postoperatively, with the quality of reduction of the fractured articular surface clarified by the final follow‐up. The flexion and extension abilities of the knee joint were also measured in the postoperative follow‐up.ResultsPreoperative CT scanning showed that the gap of the tibial plateau was 8.00 ± 1.40 (5–24) mm. The heights of the fracture of the articular surface at all three sites during the final follow‐ups were significantly different from the height before the surgery (P < 0.05). The vertical distance between the articular line and the highest point of the articular surface after reduction was 0.17 ± 0.05 mm. Anatomic reductions were obtained in 24 patients. The Rasmussen functional score after surgeries was 27.25 ± 0.94 points. Bony union was achieved in all the patients. According to the Rasmussen radiological criteria, the scores during the last follow‐up were as follows: the total score was 13–18 points, with an average of 16.00 ± 1.72 points; the scores were excellent in 17 cases and good in seven cases. Therefore, 100% of results were excellent or good. No infection or fracture nonunion was found.ConclusionUsing a horizontal plate can be an effective method for treating special types of fractures of the tibial plateau, including the anterior margin and anterolateral and posterolateral tibial plateau, with satisfactory treatment efficacy.     

Laparoscopic Ureterolithotomy

Background and Objective:

The present study retrospectively analyzed the data of 213 patients who underwent laparoscopic ureterolithotomy.

Methods:

We retrospectively analyzed the data of 213 patients, in whom we performed conventional laparoscopic ureterolithotomy from April 2006 and January 2015 based on the diagnosis of an upper or middle ureteral stone. Patients with large ureteral stones (>15 mm) or a history of failed shock-wave lithotripsy or ureteroscopy were included in the study. Although the retroperitoneal approach was preferred for 170 patients, the transperitoneal approach was used in the remaining 43 patients.

Results:

The mean patient age was 39.3 ± 12.0 years (range, 18–73). The study population was composed of 78 (26.7%) female and 135 (63.3%) male patients. The mean stone size was 19.7 ± 2.5 mm. The mean operative time was 80.9 ± 10.9 minutes, and the mean blood loss was 63.3 ± 12.7 mL. Intraoperative insertion of a double-J catheter was performed in 76 patients. The overall stone-free rate was 99%. No major complication was observed in any patient. However, conversion to open surgery was necessary in 1 patient.

Conclusion:

With high success and low complication rates, laparoscopic ureterolithotomy is an effective and reliable method that ensures quick recovery and may be the first treatment option for patients with large, impacted ureteral stones, as well as for those with a history of failed primary treatment.     

Anatomical study of anterior supramalleolar artery and its potential application to design a bi-foliate fasciocutaneous flap

Purpose:A further understanding of the anterior supramalleolar artery (ASMA) and its potential applications in reconstructive surgery.Results:We found four types of origin of the ASMA, and we have accordingly classified them into four types. 10 of them were type A, 7 were type B, 6 were type C and 1 was type D. The mean O-R (origin of ASMA to retinaculum) distance was 2.0 ± 0.8 cm. The diameter of the medial branch (D1), the diameter of the lateral branch (D2), and the diameter of artery stem (D3) (only in type A) were 1.0 ± 0.2 mm, 0.8 ± 0.3 mm, 1.1 ± 0.2 mm, respectively. The mean pedicle length of the lateral flap (L1) and medial flap (L2) were 5.1 ± 1.0 cm and 3.7 ± 0.6 cm, respectively.Conclusions:The ASMA exists constantly with four different types of origin. Its sizable diameter and lengthy pedicle make it suitable for bi-foliate fasciocutaneous flap transfer.KEY WORDS: Anterior supramalleolar artery, bipaddle flaps, fasciocutaneous flaps, multiple defects     

Anteroinferior Psoas Technique for Oblique Lateral Lumbar Interbody Fusion: Technical Note and Case Series

ObjectiveThe aim of the present paper was to evaluate cases of lumbar degenerative diseases treated with oblique lateral interbody fusion (OLIF) using a modified lateral approach (i.e. anteroinferior psoas exposure under direct vision) and to analyze the effect and safety of this approach.MethodsFrom June 2016 to April 2019, a total of 226 patients with an average age of 65.5 ± 16.2 years (98 men and 128 women) with degenerative lumbar diseases who underwent the AIP approach of OLIF were followed up and analyzed retrospectively. Data concerning operative and clinical parameters were collected, including operative time, intraoperative estimated blood loss, duration of postoperative hospital stay, and time to ambulation after surgery. For the assessment of clinical outcomes, the visual analogue scale (VAS) score (for back pain) and the Oswestry disability index (ODI) were calculated. Complications were also recorded as surgical exposure approach‐related complications. More than 6 months after surgery, 132 patients consented to having MRI examinations to evaluate the psoas muscle atrophy when they were followed up.ResultsThe mean operative time was 82.5 ± 31.6 min. The mean operative time for each segment of OLIF was 43.3 ± 15.5 min. The mean blood loss was 48.0 ± 11.6 mL. The mean blood loss for each segment of OLIF was 25.3 ± 10.1 mL. No patients needed blood transfusion intraoperatively or postoperatively. The mean hospital stay was 4.1 ± 2.1 days. All patients were followed up for 12–31 months (mean 18.2 months). Clinical assessment showed that the VAS and ODI scores at 6 months after surgery were markedly lower than the preoperative scores (P < 0.001) but did not differ from the scores at the final follow‐up (P > 0.05). There was no significant difference in percentage changes of the cross‐sectional area of the lean psoas muscle and the T2 signal intensity ratio of gross psoas to quadratus lumborum muscles between the left side (operative side) and the right side (nonoperative side) (P > 0.05). A total of 11 surgical exposure approach‐related complications were reported, with an incidence of 4.9%: transient thigh pain/numbness, psoas weakness (2.2%), sympathetic chain injury (1.3%), cage subsidence (0.9%), and segmental artery injury (0.4%). There was no permanent motor neurological deficit, and no injury of vascular, ureter or peritoneal membranes.ConclusionThe anteroinferior psoas approach for OLIF is safe and can preserve the psoas and lumbar plexus.     

Transurethral cystolitholapaxy with the AH-1 stone removal system for the treatment of bladder stones of variable size

Background

The treatment of large volume bladder stones by current equipments continues to be a management problem in both developing and developed countries. AH-1 Stone Removal System (SRS) invented by us is primarily used to crush and retrieve bladder stones. This study evaluated the safety and efficiency of transurethral cystolitholapaxy with SRS for the treatment of bladder stones of variable size.

Methods

SRS, which was invented by Aihua Li in 2007, composed by endoscope, continuous-flow component, a jaw for stone handling and retrieving, lithotripsy tube, handle, inner sheath and outer sheath. 112 patients with bladder stones were performed by transurethral cystolitholapaxy with SRS since 2008. We compare the surgical outcome to bladder stones of variable size, and evaluate the surgical efficiency and safety.

Results

Characteristics of patients and stone removal time in variable size were evaluated. To patients with single stone, stone size was 1.35 ± 0.37 cm and the operating time was 5.50 ± 3.92 min in Group A. Stone size was 2.38 ± 0.32 cm and the operating time was 11.90 ± 9.91 min in Group B. Stone size was 3.30 ± 0.29 cm and the operating time was 21.92 ± 9.44 min in Group C. Stone size was 4.69 ± 0.86 cm and the operating time was 49.29 ± 30.47 min in Group D. The difference was statistically significant between the four groups. Among them, 74 (66.07%) patients accompanied with benign prostatic hyperplasia (BPH) were treated by transurethral resection of the prostate (TURP) simultaneously. Compared between the four groups, the difference of the TURP time was not statistically significant, P >0.05. No significant complication was found in the surgical procedure.

Conclusions

Transurethral cystolitholapaxy with SRS appears to be increased rapidity of the procedure with decreased morbidity. It is a safe and efficient surgical management to bladder stones. This endoscopic surgery best fits the ethics principle of no injury; meanwhile, the accompanied BPH could be effectively treated by TURP simultaneously.     

An analysis of pre-operative Pao2 in a general surgical population

Two hundred and thirty one patients awaiting elective surgery were divided on the basis of spirometric examination into normal (group A) and those with increased airway resistance (group B). The mean arterial oxygen tension for the 151 normal subjects was 96·3 (± 11·6) mm. Hg. There was a significant inverse correlation of Pao₂ with age and dynamic lung volumes. The 80 patients in group B were significantly older and their mean Pao₂ was 88·7 (± 12·9) mm. Hg. There was, however, no correlation between Pao₂ and age in this group, probably because the increased airway resistance had a greater influence in lowering the arterial oxygen tension than did the age factor alone.