Oral soft tissue biopsy surgery: Current principles and key tissue stabilization techniques

There are different kinds of benign and malignant lesions in the oral cavity. Clinically, definite diagnosis can be confirmed only by doing adequate surgical biopsy and subsequent histopathological examination. Inadequate biopsy technique, unsuitable selection of the location for biopsy, inappropriate tissue handling and record of patients' information may lead to artifacts and misdiagnosis by the oral pathologists. Soft tissue stabilization is a challenge during oral surgery procedures. It needs the cooperation of operator, assistants, and patients to overcome the difficulty and ensure the successful outcome. In this article, we reviewed the procedures for clinical surgical biopsy, and raised three current tissue stabilization methods including fingers and gauze stabilization, stabilization with chalazion forceps and adapted instruments, and stabilization with retraction sutures. Moreover, some limitations were also presented. Clinician should examine the clinical characteristics of the oral lesion, the surrounding anatomical structures, and their own clinical experience and preference to select the appropriate tool. More understanding of these biopsy and tissue stabilization methods can effectively improve the biopsy procedures and obtain adequate tissues for histopathological examination and subsequent issue of an accurate pathological report.

Novel suspension system for gasless transoral vestibular thyroidectomy

BACKGROUND

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is receiving increased attention, frequently due to growing requirements for cosmetic incisions. Here, we report our initial experience and discuss the safety and efficacy of the innovative surgical working space suspension system for gasless TOETVA.

METHODS

We retrospectively analyzed 75 consecutive patients for whom gasless TOETVA with our novel working space suspension system was used. This suspension system included self-developed retractors, a sterile bandage, and an anesthesia stand. We also improved some main surgical instruments in gasless TOETVA.

RESULTS

The study included 75 patients who successfully underwent thyroidectomy and central neck dissection via gasless TOETVA. The mean operating time was 143.27 ± 34.60 min. The mean number of retrieved lymph nodes was 8.00 ± 5.39. Conversion to open surgery did not occur, nor did patients exhibit serious postoperative complications. Postoperative complications included 4 cases of transient recurrent laryngeal nerve (RLN) palsy, 9 of transient hypoparathyroidism, and 3 of transient mental nerve injury. One patient with subcutaneous fluid after surgery recovered after aspiration. Another patient with submental minor perforation recovered well after suturing. There was no evidence of specific complications related to self-designed retractors.

CONCLUSION

The innovative working space suspension system for gasless TOETVA provided enough and stable working space and optimized the clarity of the surgical field without CO₂-related complications.

Modified Taylor Retractor in Unilateral Subperiosteal Lumbar Microdiscectomy: A Frugal Alternative to the Tubular Retractor

OBJECTIVE

To do a comparative surgical outcome and cost-benefit analysis of our simple modified Taylor retractor with both open and tubular techniques in lumbar discectomy.

METHODS

We retrospectively divided 52 lumbar disc patients operated by 2 different techniques between January 2019 and June 2020 into 2 groups- group 1 (n = 20): standard open macrodiscectomy (4-5 cm incision); group 2 (n = 32): unilateral translaminar microdiscectomy using our modified Taylor retractor with a small incision (18-20 mm, comparable to the tubular retractor). We compared both groups in terms of surgical outcomes and cost-benefit analysis. In addition, a cost-benefit comparison between our modified Taylor technique and that of the already published tubular microdiscectomy cohort was done.

RESULTS

Complete symptom resolution occurred in 85% group 1 and 84.4% group 2 patients, with no difference in complication rates. Mean hospital stay was significantly less in group 2 (1.2 ± 0.37 days) as compared with group 1 (2.4 ± 1.15, P < 0.001). The mean total cost per patient was $2253.17 ± 69.16 in the modified Taylor microdiscectomy group compared with $2495.76 ± 214.85 (P < 0.001) in standard macrodiscectomy. Compared with the previously published tubular microdiscectomy cohort ($3069.91 ± 69.16), the modified Taylor retractor was $816.74 cheaper per patient with similar length of incision, surgical outcome, and hospital stay.

CONCLUSIONS

Similar clinical outcomes at decreased costs are obtained using the modified Taylor retractor compared with the tubular retractor. The modified Taylor retractor has a simple design, is user-friendly, and frugal alternative to the tubular retractor system for microscopic discectomy, especially in the resource-constrained countries.

Design and development of a new type of phimosis dilatation retractor for children

BACKGROUND

Phimosis is one of the most common diseases in children. Early selection of appropriate treatment for phimosis in children is beneficial to the development of their reproductive organs and significantly improves the prognosis of phimosis in children. Although traditional circumcision is the most widely used, it has many disadvantages, including postoperative bleeding and incision infection, pain, obvious scars on the surgical incision, and unsatisfactory appearance. In addition, there is much controversy regarding treatment options and timing at home and abroad. Surgical procedures such as circumcision and cerclage for children with excessively long foreskin will greatly affect the normal life of children after the operation. Young children need general anesthesia, but this anesthesia carries a great risk.

AIM

To design a new children phimosis dilatation retractor for children phimosis.

METHODS

The children phimosis was dilated with an elastic dilation frame, in order to expand the foreskin mouth and expose the penis head, and after that, the phimosis was cured.

RESULTS

A new type of phimosis dilatation retractor was designed, which can gently dilate the prepuce at multiple angles and in multiple directions at the same time. It has obtained the national patent for clinical application.

CONCLUSION

The phimosis dilatation retractor based on the principle of elastically expanding the prepuce can achieve the purpose of expanding the phimosis. The clinical application shows that the effect of the children phimosis retractor is significant, which is worth promoting.

Prospective Evaluation of the Need for Fixed Brain Retractors During Complex Cranial Surgery

OBJECTIVE

The trend toward minimally invasive surgery has led to a reduction in the size of craniotomies, use of endoscopic assistance to minimize the surgeon's footprint and aid with visualization, and use of alternatives to microsurgery, such as endovascular embolization for aneurysms and radiosurgery for skull base pathologies. A movement away from the use of fixed retractors has also been heralded as an advance in skull base surgery, but the data on the utility of a retractorless approach is small and limited to highly experienced surgeons, often with several decades of experience. This has led some to suggest that retractorless surgery may be unsafe, especially in the hands of young surgeons, in an era where the majority of complex vascular pathology has transitioned to endovascular treatment, and many skull base lesions are treated with chemoradiotherapy adjuncts.

METHODS

This 19-month study prospectively analyzed the use of retractorless surgery in a consecutive series of 139 lesions in 119 patients with complex intracranial vascular and skull base pathology undergoing craniotomy by a single surgeon.

RESULTS

The microsurgical approaches included orbitozygomatic craniotomy (40 [28.7%]), supratentorial nonskull base approaches (25 [17.9%]), pterional/minipterional (16 [11.5%]), interhemispheric (12 [8.6%]), suboccipital (11 [7.9%]), and an array of other approaches, such as presigmoid, supracerebellar-infratentorial, far lateral, and retrosigmoid approaches. The most common pathology included aneurysms (47 [33.8%]), skull base tumors (32 [23%]), deep-seated lesions (24 [17.3%]), cavernous malformations (10 [7.2%]), arteriovenous malformations (10 [7.2%]), and arteriovenous fistulae (5 [3.6%]). Of the 139 lesions, 8 (5.75%) cases required the use of a fixed retractor. In total, 94.25% of the cases were successfully treated without a self-retaining retractor system.

CONCLUSIONS

Retractorless surgery can be performed safely, even by young surgeons, in an era where the majority of complex neurovascular and skull base pathology is treated by endovascular and radiosurgical means. Retractorless surgery can be used in the majority of cases, especially if careful attention is paid to patient positioning, microsurgical dissection of arachnoid planes is carried out to access deep corridors, gravity retraction is used in lieu of fixed retractors, and judicious dynamic retraction with the shafts of instruments replaces the blades of a fixed retractor system.

Improvements to the retractor and muscle flap design for minimally invasive cochlear implantation

Objective

The aim of this study was to improve muscle flaps and to evaluate surgical outcomes with the use of a novel specialized retractor, which is a surgical instrument used to locate and shape a bony seat for minimally invasive cochlear implantation.

Methods

50 patients aged 1-75 years with sensorineural hearing loss who required cochlear implantation were recruited. A small incision (<3 cm) was made, and the novel specialized retractor was used in the study group during cochlear implantation. The incision length, surgical outcomes and operative time were recorded and analyzed.

Results

The incision length, total operative time and drilling bony time were shorter in the study group than in the control group (P < 0.05, respectively). All patients recovered well after the surgery without any severe complications.

Conclusion

The use of a novel specialized retractor standardized the surgical processes of cochlear implantation. The retractor helped locate and control the size of the bony well during bone drilling. The tool reduced the technical difficulty and improved the efficacy of this minimally invasive operation.

Retraction of Orbital Soft Tissue During Orbital Surgery: A Technical Note

Introduction

Orbital fractures may be either isolated or part of midface fractures. These injuries may cause disruption of the orbital walls and herniation or entrapment of orbital contents resulting in enophthalmos or diplopia.

Methods

Surgical exploration of the orbit is the definitive mode of management of such injuries. A common problem encountered during such exploration is the prolapse of orbital soft tissues which hamper the visualization of the defects.

Conclusion

Here, we suggest an adjunct to the orbital retractors in control prolapsing soft tissues.

A novel omnidirectional tin-alloyed ring retractor for craniotomy in neurosurgery: technical note

In neurosurgical operations, proper craniotomy using retractors is necessary. Various surgical instruments are used for this purpose, including standard retractors and multipurpose head frame retractor systems. However, the conventional multipurpose head frame system is often not optimal for use in some craniotomies and postures because of its size and complexity of setting. We have invented a new omnidirectional tin-alloyed (ODT) ring retractor for craniotomy with malleability and shape memory characteristics to resolve these issues. It is principally elliptical in shape, approximately 30 × 20 cm in diameter, and sufficiently firm. Accordingly, this ODT ring can retract the surgical field in all directions. Here, we report our experiences of 281 neurosurgical craniotomies using this ODT ring retractor system in various craniotomy sites and postures. Our novel ODT ring retractor is useful because of its low profile, multidirectional retractability, and less obstructiveness with its malleability. It could be used with pediatric patients where strong traction is not desirable.

Retractor in retractor technique

Placing retractor and stabilization devices during open heart surgery can be difficult in obese patients due to extremely short neck and excessive breast tissue. Off-pump coronary bypass operations in these patients can be particularly technically demanding. To overcome this difficulty, we have used two retractors concomitantly. The first retractor is placed to the edges of sternum and the second one is placed into this first retractor. This maneuver ensures an extra height, and placing stabilization devices in this second retractor is relatively easy. Thus, we suggest that adding this maneuver will facilitate off-pump coronary bypass operations.

Use of Alexis retractor in thyroid and parathyroid surgery

In thyroid and parathyroid surgical procedures, good visibility of the thyroid gland is essential. This is traditionally achieved by means of traction sutures of the dermo-plastysmal flaps to the drapes of the operative field, producing tension and even damage to the skin. The Alexis^® retractor ring improves exposure and facilitates stable access to the thyroid, protecting the skin from injury during the intervention.

The Radiographic Effects of Surgical Approach and Use of Retractors on the Brain After Anterior Cranial Fossa Meningioma Resection

OBJECTIVE

There is an increasing trend toward skull base (SB) approaches and retractorless surgery to minimize brain manipulation during surgery. We evaluated the radiographic changes over time after surgical resection of anterior cranial fossa meningiomas with and without both SB approaches and/or fixed retractor systems.

METHODS

All adults undergoing primary resection of an anterior cranial fossa World Health Organization grade I meningioma through a craniotomy at a single academic tertiary-care institution from 2010 to 2015 were retrospectively reviewed. Magnetic resonance imaging scans were reviewed and contrast-enhanced tumor and fluid-attenuated inversion recovery (FLAIR) volumes were measured. Matched-pair analyses between patients who underwent SB and non-SB approaches, as well as retractorless and retractor-assisted (RA) surgery, were made.

RESULTS

Of the 136 total patients, 20 (15%), 12 (9%), 46 (34%), and 58 (43%) underwent SB/retractorless, SB/RA, non-SB/retractorless, and non-SB/RA surgery, respectively. Patients who underwent non-SB and RA surgery each independently had longer times to FLAIR resolution than those who underwent SB (20.9 vs. 5 months; P = 0.04) and retractorless (12 vs. 5.2 months; P = 0.02) surgery, respectively. Patients who underwent both non-SB and RA surgery had the longest median time to FLAIR resolution (30 months vs. 4 months in SB/retractorless, 3.6 months in SB/RA, and 3 months in non-SB/retractorless; P < 0.05).

CONCLUSIONS

The use of SB approaches in combination with retractorless surgery may decrease the duration needed for FLAIR resolution after surgery. The results from this study therefore advocate SB approaches and retractorless surgery along the anterior SB when possible.

Utilising the Alexis Retractor for lateral orbital access, a case series

Lateral orbital surgery is challenging and typically involves the use of multiple traction sutures and retractors. This case series describes a novel technique utilising the Alexis retractor to provide access for lateral orbital surgery. Thirteen cases were included and the surgical technique has been described and illustrated. There were no post-operative infections or complications and the Alexis retractor provided excellent exposure whilst reducing the need for further surgical retractors.

The Availability of a Tin-Alloyed Omnidirectional Retractor-Supporting Ring for Ventriculoperitoneal Shunt Laparotomy

OBJECTIVE

We report the availability of a newly developed, malleable, tin-alloyed omnidirectional retractor-supporting (OD) ring for steady and safe ventriculoperitoneal (VP) shunt laparotomy.

METHODS

The OD ring is principally circular in shape, 15 cm in diameter, and is sufficiently malleable to be fitted to the abdominal wall. There are 22 outward protrusions 12 mm in length that are welded to the outside of the ring at regular intervals. The OD ring with twisted rubber bands attached around the protrusions is placed on the abdominal wall surrounding the skin incision. Then the edge is omnidirectionally retracted with blunt minihooks attached to the rubber bands. In our hospital from January 2016 to February 2017, 15 consecutive patients underwent a VP shunt procedure using the OD ring.

RESULTS

In a VP shunt procedure, our malleable, tin-alloyed OD ring could be smoothly placed on various types of abdominal walls. Moreover, our OD ring system provided a wider and shallower operative field allowing omnidirectional retraction during small laparotomy. Additionally, the OD ring system did not interfere with our surgical manipulations.

CONCLUSIONS

Our newly developed retraction system with a malleable, tin-alloyed OD ring and minihooks may allow safe and steady small laparotomy for VP shunt.

Independent Roll-Down Ring for Contained Tissue Extraction

An independent roll-down ring can be used to improve exposure during contained tissue extraction. We have used this technique in approximately 50 cases to date with good success. In this article we briefly describe our technique.

Mastectomy technique using a self-designed self-retaining retractor system

Mastectomy is one of the most common procedures for treating breast cancer. It is often performed by a breast surgeon with an assistant holding the retractor to provide adequate tension for dissection of the skin flap. However, the technique is highly dependent on the retraction from the assistant. We herein describe a novel technique using a self-retained retractor system with a specially designed retractor ring and elastic stay hooks to allow adequate and constant tension of retraction throughout the entire mastectomy procedure. This new technique was introduced at our breast center in 2008, and the skin flap necrosis rate and time required for skin flap dissection remain comparable to those in other regions. The retractor ring costs less than $200 USD, and the disposable elastic hooks cost around $50 USD. In conclusion, this new technique is simple, versatile, and effective.

Prospective comparison of rectal dose reduction during intracavitary brachytherapy for cervical cancer using three rectal retraction techniques

PURPOSE

To compare three rectal retraction methods on dose to organs at risk, focusing on rectal dose, in cervix cancer patients treated with high-dose-rate intracavitary brachytherapy.

METHODS AND MATERIALS

A prospective study was conducted on patients with cervical carcinoma treated with chemoradiotherapy, including external beam radiation and four fractions of high-dose-rate intracavitary brachytherapy prescribed to Point A using a ring and tandem applicator under conscious sedation. Rectal retraction methods included: a rectal retractor blade (RR), vaginal gauze packing (VP), and a tandem Foley balloon (FB). All three methods were used in all patients. The RR was used first, and the following applications were randomly assigned to VP or FB. CT planning was used to calculate D2cc for rectum, sigmoid, small bowel, and bladder. The Wilcoxon signed rank test was used to determine if the median dose differences between methods were statistically significant.

RESULTS

In these 11 patients, median dose (min, max) in cGy to the rectum using RR, FB, and VP was 131 (102, 165), 199 (124, 243), and 218 (149, 299), respectively. The RR demonstrated lower median intrapatient doses to rectum compared with FB and VP (-55 cGy; p = 0.014 and -76 cGy; p = 0.004, respectively). The RR also resulted in lower sigmoid doses. No differences in dose were observed between the VP and FB methods.

CONCLUSION

The rectal retractor significantly reduced the dose to rectum and sigmoid compared with FP and VP. In patients treated under conscious sedation, the RR method provides the best rectal sparing. There were no significant differences in dose observed between the FB and VP techniques.

Use of the Lumitex MD Lightmat® Surgical Illuminator for pediatric genital trauma cases: a retrospective case series

STUDY OBJECTIVES

To review the literature regarding repair of pediatric female genital trauma. To review our experience with the use of a lighted retractor at the time of repair of genital trauma in an operating room setting.

STUDY DESIGN

Retrospective case series.

SETTING

Texas Children's Hospital.

PARTICIPANTS

Patients with genital trauma requiring repair in an operating room setting where the Lumitex MD Lightmat Surgical Illuminator (LM) was utilized.

INTERVENTIONS

Use of the LM in pediatric gynecology patients.

RESULTS

Of the 16 cases where the LM lighted retractor was utilized, 12 were found to be performed secondary to genital trauma, resulting from straddle injury or coital trauma. Four patients were identified as having either congenital reproductive tract anomalies or foreign body. Patients ranged in age from 1-21 years with a mean age of 9 ± 4.91 years at the time of their vaginal repair. The mean operative time was 82 ± 47 minutes, with cases ranging from 37-182 minutes, with a median blood loss of 7 mL and an average hospital stay of 1.2 days. There were no surgical complications.

CONCLUSION

Neurosurgeons and otolaryngologists have been optimizing safe visualization of small areas during surgery for years with the use of the LM. In cases of pediatric deep genital trauma, the LM can be used safely for easy visualization, allowing for direct visualization in cases of deep genital trauma.

Retraction-Related Acute Liver Failure after Urological Laparoscopic Surgery

Liver retraction is necessary for optimal exposure during laparoscopic right renal surgery. We described a patient who developed fulminant liver failure as a result of liver retractor-induced excessive ischemic changes in the right lobe of the liver. A 37-year-old male underwent a right side laparoscopic pyeloplasty for ureteropelvic junction obstruction. At the beginning of the operation, a small snake retractor was placed through a 5-mm port under direct vision. The liver was lifted in the appropriate direction to optimize exposure by using the laparoscope holder. The operation was prolonged. However, we achieved significant improvements in the efficiency of liver retraction using the holder. On the first postoperative day, the patient's serum levels of GOT, GPT and LDH had remarkably increased. A computerized tomogram confirmed the presence of excessive ischemic changes of the right lobe of the liver. Our method which used a laparoscope holder device for liver retraction maintained a better surgical field. However, neglecting to make minor adjustments to the positioning of the retractor can cause significant pressure on the liver parenchyma in a single area. As surgical procedures increase in complexity, the surgeon should keep these potential side effects in mind and shift the retraction point at regular intervals. In this report, we discussed various types of retractor-related liver injuries and their management, and highlighted the importance of intermittent release of retraction during prolonged surgery.

Comparative analysis of rectal dose parameters in image-guided high-dose-rate brachytherapy for cervical cancer with and without a rectal retractor

PURPOSE

The objective of this study was to determine if use of a rectal retractor (RR) in high-dose-rate intracavitary brachytherapy for cervical cancer reduces rectal dose parameters.

METHODS AND MATERIALS

We reviewed data obtained from patients treated with intracavitary brachytherapy for cervical cancer with and without an RR. Treatment plans for each brachytherapy fraction were separated into two groups; R group with use of an RR and P group with use of vaginal packing. Dose-volume parameters for high-risk clinical target volume (HR-CTV), rectum, sigmoid, small bowel, and vaginal surface were collected for each fraction. Rectal D2cc and International Commission on Radiation Units & Measurements (ICRU) rectal point doses were compared between groups using Student's t tests. Predictors of higher rectal D2cc were determined by univariate and multivariate regression analyses.

RESULTS

Four hundred sixty-three brachytherapy fractions from 114 patients were used for analysis, 377 fractions with a RR (R group) and 86 with vaginal packing only (P group). Both groups were similar except for slightly higher mean HR-CTV and mean bladder volume in P group. Both mean ICRU rectal point dose (241.1 vs. 269.9 cGy, p = 0.006) and rectal D2cc (240.6 vs. 283.6 cGy, p < 0.001) were significantly higher in P group. Point A dose, HR-CTV, stage, and use of an RR were significant predictors of rectal D2cc on multivariate analysis.

CONCLUSIONS

Our data show that use of an RR leads to lower rectal dose parameters compared with vaginal packing. Further study is needed to determine if this will lead to less long-term toxicity.

An innovative wound retractor/protector for prosthetic urologic surgery

OBJECTIVE

We demonstrate an innovative use of a barrier surgical wound retractor/protector system for use in a variety of prosthetic urologic procedures (penile prosthetics, artificial urinary sphincters, male slings).

MATERIALS AND METHODS

We demonstrate the use of a self-retaining ring wound retractor in a multitude of prosthetic urological procedures: insertion of an inflatable penile prosthesis through an infrapubic approach as well as penoscrotal approach, placement of a transperineal artificial urinary sphincter, and placement of a male urethral sling.

RESULTS

The self-retaining ring wound retractor facilitated a more rapid setup and takedown, provided 360 degrees of atraumatic retraction as well as 360 degrees of wound protection, allowed for maximum exposure with a minimum incision size, significantly shortened the operating wound depth thus maximizing exposure, and isolated the surgical field minimizing prosthesis to skin contact.

CONCLUSION

Our experience shows that prosthetic urologic surgeries can be enhanced with the use of the self-retaining ring wound retractor as it provides better surgical exposure, lowers wound infection risks, sets up more quickly as a safer retraction system with substantial cost savings.