Pre-Incisional and Multiple Intradermal Injection of N-Acetylcysteine Slightly Improves Incisional Wound Healing in an Animal Model

The objective of this study was to investigate if delivering multiple doses of N-acetylcysteine (NAC) post-surgery in addition to pre-incisional administration significantly impacts the wound healing process in a rat model. Full-thickness skin incisions were carried out on the dorsum of 24 Sprague-Dawley rats in six locations. Fifteen minutes prior to the incision, half of the sites were treated with a control solution, with the wounds on the contralateral side treated with solutions containing 0.015%, 0.03% and 0.045% of NAC. In the case of the NAC treated group, further injections were given every 8 h for three days. On days 3, 7, 14 and 60 post-op, rats were sacrificed to gather material for the histological analysis, which included histomorphometry, collagen fiber organization analysis, immunohistochemistry and Abramov scale scoring. It was determined that scars treated with 0.015% NAC had significantly lower reepithelization than the control at day 60 post-op (p = 0.0018). Scars treated with 0.045% NAC had a significantly lower collagen fiber variance compared to 0.015% NAC at day 14 post-op (p = 0.02 and p = 0.04) and a lower mean scar width than the control at day 60 post-op (p = 0.0354 and p = 0.0224). No significant differences in the recruitment of immune cells and histological parameters were found. The results point to a limited efficacy of multiple NAC injections post-surgery in wound healing.

Single Port Modified Partial Nephrectomy: Novel Simultaneous Access to Peritoneal and Retroperitoneal Partial Nephrectomy, Initial Clinical Experience

Introduction and Objective: Since its Food and Drug Administration (FDA) approval in 2018, Intuitive Surgical DaVinci single port (SP) robotic platform has been an effectively used technology for multiple urologic procedures. The purpose of this study is to share our early intraoperative and perioperative outcomes and potential benefits for performing a lower anterior access (LAA) incision for SP robot-assisted partial nephrectomy (SP-RAPN). The LAA incision enables performing a trans- or retroperitoneal (RP) approach through the same incision and eases the transition to a RP approach. Methods: This study is a prospective review of 78 SP-RAPN cases between March 2021 and January 2023 by an experienced robotic surgeon. A single 2-3 cm oblique incision parallel to the external oblique muscle, one-third of the distance between the iliac crest and umbilicus, was used to insert the multichannel port to perform the RAPN. We extracted intra- and perioperative data of these patients to share the outcomes of this approach. Results: SP-RAPN was effectively completed in 78 patients (38 females and 40 males) without conversion to open or laparoscopic techniques. The mean age was 61.2 ± 12.1 years. The mean tumor size was 3.0 ± 1.2 cm, 43 were right-sided masses, and 35 were left sided. The R.E.N.A.L Nephrometry score ranged from (4-11) with an average of 7.0 ± 1.9. Average operating room time was 90.5 ± 24.6 minutes, estimated blood loss was 88.3 ± 134 mL, and length of stay of 1.07 ± 0.7 days. Of the 78 cases, 40 required clamping of the renal artery with average warm ischemia time of 19.4 ± 6.7 minutes in patients who underwent clamping. No complications in all of 78 patients. Conclusions: This study demonstrates the feasibility and reproducibility of SP-RAPN using a LAA incision. This incision provides a standardized approach for surgeons to transition to the RP approach using the SP platform.

Hyperselective neurectomy in the treatment of elbow and wrist spasticity: an anatomical study and incision design

OBJECTIVE

Hyperselective neurectomy is used to treat spastic arm paralysis. The aim of the study was to analyze the nerve branching patterns of elbow and wrist flexors/pronator to inform hyperselective neurectomy approached.

METHODS

Eighteen upper extremities of fresh cadaver specimen were dissected. The number of motor branches from the musculocutaneous nerve to biceps brachii and brachialis, median nerve to pronator teres, flexor carpi radialis and ulnar nerve to flexor carpi ulnaris were counted. The origin site of each primary motor branch was documented.

RESULTS

Either biceps or brachialis was innervated by one or two primary motor branches. Pronator teres was innervated by one to three motor trunks and the pattern for flexor carpi radialis was a common trunk with other branches. The origin of the biceps and brachialis nerve trunk was located approximately 30% to 60% of the length of the arm. The median nerve branched to pronator teres and flexor carpi radialis at the region about 34mm (SD 18.8mm) above and 50mm (SD 14.9mm) below the medial epicondyle. Flexor carpi ulnaris was innervated by one to three motor trunks and the mean distance from the medial epicondyle to the origin of flexor carpi ulnaris nerve on ulnar nerve was 18.7 mm (SD 6.5mm).

CONCLUSION

Primary motor branches to elbow flexors, wrist flexors and pronators were various, while the regions of their origins were relatively settled. It was recommended the incisions be designed according to the location of the primary motor trunks.

Effectiveness of SCAR-Q for assessment of incisional SCAR after implant-based reconstruction in breast cancer patients: Can it be a tool for incision selection?

Incisional scarring is a factor of cosmetic appearance evaluated after breast reconstruction, along with the shape, position, and size of the breast. This study aimed to examine the effect of the incision scar location on patient satisfaction after breast reconstruction. Using the Japanese version of the SCAR-Q, we assessed the scar appearance, symptoms and psychosocial effects. Plastic surgeons performed assessments using the Manchester Scar Scale. The patients were divided into two groups: those with scars on the margins of the breast (MB group) and those with scars in the breast area (IB group). The results revealed that patients in the MB group reported significantly higher satisfaction with the scar appearance and psychological impact than those in the IB group. However, assessments using the Manchester Scar Scale did not reveal any significant differences between the two groups. In conclusion, this study underscores the importance of patient-reported outcomes in the evaluation of scar satisfaction after breast reconstruction. Patients tend to prefer and have higher satisfaction with scars along the breast margin, which offers valuable insights into surgical decisions. Further studies with larger and more diverse sample sizes are required for validation.

The Method of Portal Making in Lumbar Unilateral Biportal Endoscopic Surgery with Different Operative Approaches According to the Constant Anatomical Landmarks of the Lumbar Spine: A Review of the Literature

STUDY DESIGN

Review.

OBJECTIVE

Unilateral Biportal Endoscopy (UBE) is a minimally invasive surgery that is gaining recognition and being employed in clinical practice. Nevertheless, the precise method for determining UBE portals' location varies depending on the originator's preferences or the anatomical structure's proximity to the portal positions. Consequently, the relationship among UBE portals' locations is messy. This study aims to elaborate on the specific portal localization and explore the positional association and commonality among different UBE approaches' portals.

METHODS

The following keywords are used to search in the PubMed, Ovid, Web of Science, ScienceDirect, SpringerLink, Scopus, CNKI, and Wanfang database: "Biportal endoscopic spinal surgery", "Two portal endoscopic spinal surgery", "Percutaneous biportal endoscopic decompression", "Unilateral biportal endoscopy", "Irrigation endoscopic discectomy", "UBE" and "BESS".

RESULTS

After screening, 29 pieces of literature are included. The study summarizes different UBE approach portal localizations, categorized by fusion or non-fusion surgery and pathological classification. The study presents an inaugural method for categorizing the lumber into four surgical intervals based on bone landmarks and assigns different UBE approaches to the appropriate intervals based on their characteristics, making the selection of UBE surgical approaches' portal locations more flexible. Additionally, the study provides an overview of the indications, complications, and distinct benefits associated with each interval, further refining the novel UBE portal interval localization method.

CONCLUSION

The study clarifies the interrelationship and commonality between the portals of different UBE approaches and proposes a new UBE portal interval localization method to enhance surgeons' understanding and proficiency in UBE procedures.

Impact of Vertical and Horizontal Skin Incisions on Outcome Measures in Tracheostomies

Tracheostomy is a life-saving procedure in which an opening is created in the anterior wall of the trachea. Different skin incision types are administered in tracheostomy procedures, predominantly vertical and horizontal. Various literature on the skin incision types in tracheostomy had contradictory findings, with different studies observing that one skin incision type had better outcomes than its counterpart. Hence the objective of this study was to compare the outcomes associated with vertical and horizontal skin incisions in patients undergoing tracheostomy. Method The present study assessed the outcome measures between the two incision types (vertical and horizontal) in tracheostomy. A prospective longitudinal study was done based on an academic tertiary hospital in Bhopal, Madhya Pradesh. Participants above 18 years who underwent tracheostomy were enrolled in the study and followed up over six months during intraoperative, immediate, within seven days, and long-term periods. Result In intraoperative complications, bleeding was most common (n = 15, 16.7%), followed by passage of tube into false tract (n = 6, 6.7%) and saturation drop (n = 2, 2.2%). Immediate complications comprised T-tube blockage (n = 4, 4.4%) and bleeding (n = 1, 1.1%). Complications within seven days occurred only in the horizontal group in which stomal site ulceration (n = 4, 6.7%) and delayed bleeding (n = 2, 3.3%) was seen, and one participant had unintended decannulation. In the long term, complications observed were stomal granulation (n = 9, 19.1%), dysphagia (n = 7, 14.9%), and unintended decannulation (n = 4, 8.5%). Conclusion In the current study, the most common intraoperative complication was bleeding, the immediate complication was tube dislodgement, and tracheostomy site ulcer was the most common complication within seven days, similar to the literature findings.

Does the atrial incision affect rates of early postoperative atrial arrhythmias in mitral valve surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in patients undergoing mitral valve surgery, does atrial incision affect early postoperative rates of atrial arrhythmia'. Two hundred and four papers were found. Nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Data suggest that a transeptal incision is associated with increased rates of postoperative atrial arrhythmia compared with direct left atriotomy.

Potentially Fatal Ludwig's Angina: A Case Report

Ludwig's angina is a condition that could be fatal, causing severe diffuse cellulitis bilaterally that affects the submandibular, sublingual, and submental areas. It has an acute onset and progresses rapidly. A common and potentially deadly complication is airway impairment. Prompt diagnosis and treatment planning have the opportunity to save lives. An elective tracheostomy is recommended for the patient to maintain an open airway, followed by addressing potential affected spaces due to a widespread odontogenic infection. This infection has extended to the neck, causing elevation of the ventral surface of the tongue and floor of the mouth, leading to airway obstruction and the manifestation of stridor. In the latter stages of the illness, additional attention should be paid to maintaining the airway before surgical decompression and antibiotic treatment. In advanced cases, the usual protocol of care still includes surgical drainage of the infection, judicious administration of parenteral antibiotics, and airway management. A case report's objectives are to improve clinical knowledge, facilitate better diagnosis and treatment, and add to the body of medical research by offering a thorough and educational description of a particular patient's experience with this illness.

Chemokine receptor CXCR2 in primary sensory neurons of trigeminal ganglion mediates orofacial itch

The CXCR2 chemokine receptor is known to have a significant impact on the initiation and control of inflammatory processes. However, its specific involvement in the sensation of itch is not yet fully understood. In this study, we aimed to elucidate the function of CXCR2 in the trigeminal ganglion (TG) by utilizing orofacial itch models induced by incision, chloroquine (CQ), and histamine. Our results revealed a significant up-regulation of CXCR2 mRNA and protein expressions in the primary sensory neurons of TG in response to itch stimuli. The CXCR2 inhibitor SB225002 resulted in notable decrease in CXCR2 protein expression and reduction in scratch behaviors. Distal infraorbital nerve (DION) microinjection of a specific shRNA virus inhibited CXCR2 expression in TG neurons and reversed itch behaviors. Additionally, the administration of the PI3K inhibitor LY294002 resulted in a decrease in the expressions of p-Akt, Akt, and CXCR2 in TG neurons, thereby mitigating pruritic behaviors. Collectively, we report that CXCR2 in the primary sensory neurons of trigeminal ganglion contributes to orofacial itch through the PI3K/Akt signaling pathway. These observations highlight the potential of molecules involved in the regulation of CXCR2 as viable therapeutic targets for the treatment of itch.

FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery

FIGO is actively contributing to the global effort to reduce maternal morbidity, mortality, and disability worldwide. Cesarean delivery rates are increasing globally, without signs of slowing down. Bleeding associated with cesarean delivery has become an important cause of hemorrhage-related maternal deaths in many low- and middle-income countries. Correct surgical techniques to improve safety and reduce complications of cesarean delivery is of the utmost importance. This article presents FIGO's good practice recommendations for effective surgical techniques to reduce cesarean complications. Evidence-based information is included where data are available. An expanded WHO Surgical Safety Checklist for maternity cases is suggested. Different incision techniques through the layers of the abdominal wall with appropriate indications are discussed. Hysterotomy through a transverse incision is described, as are indications for low vertical and classical incisions. Important precautions when extracting the fetus are explained. Uterine closure includes a safe method ensuring adequate reapproximation of the upper segment if a vertical incision is made. The paper concludes with the management of two common bleeding problems following delivery of the placenta.

Comparing the intraoperative and postoperative complications of the scalpel and electrocautery techniques for severing the inner layers of the lumbar disc during discectomy surgery

Background

Due to the sensitivity of the surgical site and a higher probability of injury, the use of a scalpel and electrocautery to create an incision in the spine is discussed. In this study, we will compare the intraoperative and postoperative complications of the scalpel and electrocautery techniques for severing the inner layers of the lumbar disc during discectomy surgery.

Materials and methods

This study was conducted in Iran as a randomized controlled trial with double-blinding (1,401). Sixty candidates for spine surgery were randomly divided into two groups of 30 using electrocautery (A) and a scalpel (B) based on available sampling. The VAS scale was used to assess postoperative pain. The duration of the incision and intraoperative blood loss were recorded. The infection and fluid secretions were determined using the Southampton scoring scale. Utilizing the Manchester scar scale, the wound healing status was evaluated. The SPSS version 16 software was used for data analysis (t-test, Mann-Whitney U, ANOVA).

Results

The electrocautery group had substantially lower bleeding, pain, and wound healing rates than the scalpel group (P > 0.05). However, the electrocautery group had significantly longer surgical times, more secretions, and a higher infection rate than the scalpel group (P > 0.05). In terms of demographic and clinical characteristics, there was no significant difference between the two groups (P < 0.05).

Conclusion

Electrocautery reduces postoperative hemorrhage and, potentially, postoperative pain in patients. However, as the duration of surgery increases, so does the duration of anesthesia, and patient safety decreases. Additionally, the risk of infection increases in the electrocautery group compared to the scalpel group, and the rate of wound healing decreases.

Clinical Trial Registration

https://www.irct.ir/, identifier (IRCT20230222057496N1).

Evaluation of Wound Healing Activity of 80% Methanol Stem-Bark Extract and Solvent Fractions of Prunus africana (Hook.f.) Kalkman (Rosaceae) in Mice

Purpose

Prunus africana is a well-known plant that is used in Ethiopian traditional medicine for the treatment of wounds and other ailments, although there is no scientific evidence to back up the claims of its wound-healing properties. Thus, the objective of this study is to evaluate the wound-healing potential of P. africana bark extract in mice.

Methods

The bark of the plant was extracted by successive maceration using 80% methanol and then fractionated with aqueous, n-butanol, and chloroform. The crude extract and solvent fractions were formulated as an ointment. Wound healing activity was evaluated using excision and incision wound models. Total phenol, flavonoid, and alkaloid contents of the crude extract, aqueous, and n- butanol fractions of the plant were determined.

Results

In both models, mice treated with 5% (w/w) and 10% (w/w) crude extract ointment exhibited a significant (p < 0.001) wound healing activity compared with control as evidenced by the increased rate of wound contraction and hydroxyproline content, the reduced epithelialization time, and the higher skin breaking strength. Mice treated with aqueous fraction ointment exhibited a high percentage of wound healing effect among all solvent fractions. The aqueous fraction consisted of higher phenolic (49.71 ± 0.73 mg/g) and flavonoid (39.58 ± 0.27 mg/g) content, while alkaloid (3.89 ± 0.55 mg/g) content was the lowest.

Conclusion

Prunus africana stem bark extract demonstrated wound healing activity in mice model which supports the acclaimed use by Ethiopian traditional medicine.

Preclinical Investigation of Ab Interno Goniotomy Using Three Different Techniques

Purpose

To evaluate incisional or excisional tissue-level effects of ab interno goniotomy techniques on human trabecular meshwork (TM).

Methods

The TM from human cadaveric corneal rim tissue was treated using three devices: (1) Kahook Dual Blade (KDB) GLIDE, (2) iAccess, and (3) SION. Two human corneal rims were used for each of the iAccess and SION devices and one with the KDB GLIDE, with 360 degrees of TM treated in each case. Sections were then prepared for analysis and comparison between devices. Tissue samples underwent standard histologic processing with H&E stain, followed by comparative analyses.

Results

Areas treated with the KDB GLIDE device resulted in nearly complete excision of TM overlying the canal of Schlemm without injury to surrounding tissues. The iAccess device can be used as a focal trephine to create holes or dragged for TM disruption. When used to create holes, iAccess punched through the full thickness of the TM and also disrupted the anterior scleral tissue. It caused some incisional openings through the TM but with significant leaflets remaining and minimal true "hole-punch" effect. When the device tip was dragged, iAccess incised the TM and left debris behind with little, if any, excision of tissue. SION led to both incision and excision of TM with incision predominating over excision.

Conclusion

The various methods evaluated to perform ab interno goniotomy resulted in varying degrees of TM incision or excision. Only the KDB GLIDE device resulted in reliable excision of TM, while the other devices produced incision or minimal excision of tissue with residual leaflets and debris. Use of iAccess resulted in focal disruption of the anterior scleral wall. Because incisional approaches that leave longer residual leaflets may be more prone to fibrosis and closure compared to excisional treatments, clinical correlation will be necessary to better understand the significance of these findings with respect to relative effectiveness of intraocular pressure lowering in eyes with glaucoma.

Management of fascial space infections using ultrasonography as a surgical guide for drainage - A case series

Fascial space infections are common emergencies presented to a maxillofacial surgeon. Space infection requires early diagnosis and prompt management. When left untreated, space infection spreads and involves not just one space, but also its adjacent spaces. Abscess in the head and neck region are treated by surgical incision and drainage, along with antibiotics and removal of the causative factor. The surgical incision and drainage of an abscess, if carried out based on physical examination may result in, excessive pain, tissue trauma, unnecessary extensive incisions, excess time and failure to locate and evacuate the abscess fluid. To avoid all such complications, ultrasonography is not only an invaluable diagnostic tool but also aids in ultrasonography guided drainage of fascial space infections.

The Length of Incision in Unicondylar Knee Arthroplasty Is More Affected by the Patient's Height Than Their Weight

Objective Obesity leads to osteoarthritis due to increased loading forces on joint cartilage and inflammatory agents released from adipose tissue. In patients with a high body mass index (BMI), during hip and total knee arthroplasty, surgical technical challenges such as longer incisions and wider exposure are encountered, resulting in increased postoperative complications (wound healing problems and infection, venous thromboembolism (VTE)- pulmonary embolism (PE), dislocation, early implant failure) and ultimately decreased patient satisfaction and implant survival. This study investigates whether BMI, height, weight, and patient age are associated with longer incisions in patients undergoing unicondylar knee prosthesis (UKP) placement. Method Between January 2017 and December 2018, 30 patients (29 females and 1 male) who underwent UKP surgery due to medial gonarthrosis were included in the study. The UKP used in the procedures was the Oxford Knee Phase III by Biomet Ltd., UK. The study comprised 43 knees, 13 being bilateral cases, 8 on the right, and 9 on the left. Data regarding the patient's height, weight, BMI, age, and the operated side were collected and compiled. The relationships between these variables and the surgical incision length were statistically analyzed. Results The average age of the patients was 66.3 years, with an average weight and height of 77.6 kg (ranging from 62 to 98 kg) and 167 cm (ranging from 150 to 184 cm), respectively. The lengths of the surgical incisions ranged from 70 mm to 160 mm, with an average length of 124.5 mm. When comparing the incision lengths between the right and left sides, it was observed that the incisions on the left side were longer. The average incision length on the right side was 122.09 mm, while on the left, it was 126.86 mm. Moreover, in the 13 patients who underwent bilateral surgery, this difference in incision length was even more pronounced. The average incision length on the right side was 117.15 mm, whereas on the left, it was 124.23 mm. Bivariate correlation analyses were performed to examine the relationship between the length of the incision and BMI and age. However, no significant relationship was found between the incision length and BMI or age. On the other hand, there was a correlation between the patient's weight values and the incision length (p < 0.05, correlation 0.335). Furthermore, a higher correlation was observed between the patient's height and the incision length (p < 0.01, correlation 0.595). Conclusion The latest advances in surgical techniques and instrumentation have enabled surgeons to perform the procedure using a reliable mini-incision approach. Mid-term evaluation of UKP with mini-incision shows faster recovery and lower morbidity. The findings show that in UKP, the length of the surgical incision is more strongly related to the patient's height than their weight.

A Muscle-Preserving Short Transverse Incision for Unicompartmental Knee Arthroplasty: A Technical Note

We describe the use of a short transverse incision technique with muscle retention for unicompartmental knee arthroplasty (UKA). The incision is made transversely just above the joint line, followed by a detachment of subcutaneous soft tissue from the underlying capsule and fascia to create a mobile window. The fascia is incised along the medial border of the vastus medialis and the capsule of the suprapatellar pouch is incised laterally, preserving vastus medialis muscle. All procedures are performed within the mobile window while controlling the knee flexion angle. Following implantation, the capsule and fascia are anatomically repaired. This approach was used in 30 consecutive patients who underwent Oxford UKA, including one bi-unicompartmental knee arthroplasty without complications. Importantly, no patients had any disturbances of the infrapatellar branch of the saphenous nerve disturbances such as numbness, hyperesthesia, hypoesthesia, or neuroma pain. The transverse approach is thought to be a safe and feasible method for UKA.

Early-Life Iron Deficiency Persistently Alters Nociception in Developing Mice

Clinical association studies have identified early-life iron deficiency (ID) as a risk factor for the development of chronic pain. While preclinical studies have shown that early-life ID persistently alters neuronal function in the central nervous system, a causal relationship between early-life ID and chronic pain has yet to be established. We sought to address this gap in knowledge by characterizing pain sensitivity in developing male and female C57Bl/6 mice that were exposed to dietary ID during early life. Dietary iron was reduced by ∼90% in dams between gestational day 14 and postnatal day (P)10, with dams fed an ingredient-matched, iron-sufficient diet serving as controls. While cutaneous mechanical and thermal withdrawal thresholds were not altered during the acute ID state at P10 and P21, ID mice were more sensitive to mechanical pressure at P21 independent of sex. During adulthood, when signs of ID had resolved, mechanical and thermal thresholds were similar between early-life ID and control groups, although male and female ID mice displayed increased thermal tolerance at an aversive (45 °C) temperature. Interestingly, while adult ID mice showed decreased formalin-induced nocifensive behaviors, they showed exacerbated mechanical hypersensitivity and increased paw guarding in response to hindpaw incision in both sexes. Collectively, these results suggest that early-life ID elicits persistent changes in nociceptive processing and appears capable of priming developing pain pathways. PERSPECTIVE: This study provides novel evidence that early-life ID evokes sex-independent effects on nociception in developing mice, including an exacerbation of postsurgical pain during adulthood. These findings represent a critical first step towards the long-term goal of improving health outcomes for pain patients with a prior history of ID.

High rate of early recurrence of peritonsillar abscess among adolescents and young adults

BACKGROUND

Peritonsillar abscess (PTA) can be treated with aspiration or incision for drainage, but a subsequent PTA can occur if tonsillectomy is not performed. Better understanding is needed of when tonsillectomy should be performed to avoid PTA recurrence.

OBJECTIVE

This study investigated the recurrence rate of PTA following aspiration or incision for drainage and evaluated the risk factors for recurrence.

METHODS

The medical records of 292 patients treated for PTA were reviewed. Recurrence of PTA and elective or quinsy tonsillectomy were the primary endpoints. A Cox proportional hazards regression model for PTA recurrence was constructed with sex, age, and PTA history as predictors.

RESULTS

Young age was the only significant predictor of PTA recurrence. Patients aged 15 to 24 years had a 30-day recurrence rate of 15.5% and a total recurrence rate of 26.6%. The total recurrence rate among patients over 30 years of age was significantly less at 4.0% (Fisher's exact test, p < .05).

CONCLUSION AND SIGNIFICANCE

Based on our results, tonsillectomy should be considered for PTA patients between 15 and 25 years of age and, to effectively avoid future recurrence of PTA, should be performed urgently.

Comparison of retroauricular and reverse question mark incisions for decompressive hemicraniectomy

BACKGROUND

The retroauricular (RA) incision has several theoretical benefits compared to the reverse question mark (RQM) incision for decompressive hemicraniectomy (DHC), but limited data comparing the two exist.

METHODS

Consecutive patients who underwent DHC between 2016 - 2022 and survived ≥ 30 days at a single institution were included. The primary outcome was wound complication within 30 days (30dWC) requiring reoperation. Secondary outcomes included 90-day wound complication (90dWC), craniectomy size in anterior-posterior (AP) and superior-inferior dimensions, distance from the inferior craniectomy margin to the middle cranial fossa (MCF), estimated blood loss (EBL), and operative duration. Multivariate analyses were performed for each outcome.

RESULTS

A total of 110 patients (RA group: 27, RQM group: 83) were included. The incidence of 30dWC was 1.2% and 0 in the RQM and RA groups, respectively. The incidence of 90dWC was 2.4% and 3.7% in the RQM and RA groups, respectively. There was no difference in mean AP size (RQM: 15 cm, RA: 14.4 cm; p = 0.18), superior-inferior size (RQM: 11.8 cm, RA: 11.9 cm; p = 0.92), and distance from MCF (RQM: 15.4 mm, RA: 18 mm; p = 0.18). Mean EBL (RQM: 418 cc, RA: 314 cc; p = 0.36) and operative duration (RQM: 103 min, RA: 89 min; p = 0.14) were similar. There was no difference in cranioplasty wound complications, EBL, or operative duration.

CONCLUSION

Wound complications are comparable between the RQM and RA incisions. The RA incision does not compromise craniectomy size or temporal bone removal.

Incision and Capsular Contracture Risk: Is There a Relationship in Breast Augmentation and Augmentation/Mastopexy?

BACKGROUND

Breast implants can be introduced through a variety of incisions, most commonly an inframammary incision, but also a periareolar incision or an axillary incision. Usually, the implant is inserted through the same incision used in performing an augmentation/mastopexy. Some authors use a separate inframammary incision. Capsular contracture is the most common complication of breast augmentation. One theory holds that it is caused by an infected biofilm, prompting surgeons to minimize implant handling, known as the "no touch" technique. This review was undertaken to investigate the relationship, if any, between the access incision and the risk of capsular contracture.

METHODS

An electronic literature search was conducted to identify publications comparing capsular contracture rates by the access incision.

RESULTS

Ten studies were evaluated. Most were retrospective series. Three were prospective core studies. Some studies reported an increased risk of capsular contracture for a periareolar incision; a similar number did not. One study supported a separate inframammary incision at the time of vertical augmentation/mastopexy.

DISCUSSION

Bacterial studies in the last decade show that the resident bacteria on the skin surface and within breast tissue are similar. Sophisticated microbiological evaluation of breast capsules reveals that the microbiome relates to the patient, as opposed to a specific bacterial profile for capsular contracture. A review of the statistics used in determining an advantage for a separate incision at the time of vertical augmentation/mastopexy reveals that there is no statistically significant risk reduction when using an additional inframammary incision, which adds an unnecessary scar.

CONCLUSIONS

The access incision at the time of breast augmentation or augmentation/mastopexy is unlikely to affect the capsular contracture risk. There is no need to make a separate incision to insert the implant at the time of augmentation/mastopexy, or to isolate the implant from contact with breast parenchyma. Little evidence supports the "no touch" technique. The etiology of capsular contracture remains unknown.

Phenotype- and species-specific skin proteomic signatures for incision-induced pain in humans and mice

BACKGROUND

Acute pain after surgery is common and often leads to chronic post-surgical pain, but neither treatment nor prevention is currently sufficient. We hypothesised that specific protein networks (protein-protein interactions) are relevant for pain after surgery in humans and mice.

METHODS

Standardised surgical incisions were performed in male human volunteers and male mice. Quantitative and qualitative sensory phenotyping were combined with unbiased quantitative mass spectrometry-based proteomics and protein network theory. The primary outcomes were skin protein signature changes in humans and phenotype-specific protein-protein interaction analysis 24 h after incision. Secondary outcomes were interspecies comparison of protein regulation as well as protein-protein interactions after incision and validation of selected proteins in human skin by immunofluorescence.

RESULTS

Skin biopsies in 21 human volunteers revealed 119/1569 regulated proteins 24 h after incision. Protein-protein interaction analysis delineated remarkable differences between subjects with small (low responders, n=12) and large incision-related hyperalgesic areas (high responders, n=7), a phenotype most predictive of developing chronic post-surgical pain. Whereas low responders predominantly showed an anti-inflammatory protein signature, high responders exhibited signatures associated with a distinct proteolytic environment and persistent inflammation. Compared to humans, skin biopsies in mice habored even more regulated proteins (435/1871) 24 h after incision with limited overlap between species as assessed by proteome dynamics and PPI. Immunohistochemistry confirmed the expression of high priority candidates in human skin biopsies.

CONCLUSIONS

Proteome profiling of human skin after incision revealed protein-protein interactions correlated with pain and hyperalgesia, which may be of potential significance for preventing chronic post-surgical pain. Importantly, protein-protein interactions were differentially modulated in mice compared to humans opening new avenues for successful translational research.

Evaluation of Wound Healing Potential of Root Bark Extract of Berberis Aristata and Molecular Docking Analysis of Berberis Phytoconstituents

INTRODUCTION

The root bark of Berberis aristata has been utilized by indigenous peoples for wound treatment for centuries. The mature root barks are crushed into a paste and applied to the wound's surface.

OBJECTIVE

The focus of this research is to analyse the wound healing activities of an ethanolic extract of Berberis aristata, as well as to use molecular docking to establish the likely mechanism of the potent phytochemical. There is no scientific evidence to support the usage of root bark extract of Berberis aristata.

METHOD

The Herbal ointment, which comprises (1%, 2%, and 4% w/w) ethanolic extract of root bark, was developed to test the wound healing ability of incision and excision wounds, and the molecular mechanism was established using Auto-Dock software.

RESULT

Epithelization stage, wound index, % wound contraction area, hydroxyproline content, DNA estimate, and histopathological assessments were performed on the incision wound model. Tensile strength was assessed in an excision wound model. TLC was used to identify the samples after successive extractions with different solvents based on polarity.

CONCLUSION

Berberine and Tetrahydropalmatine were major active phytoconstituent found in root barks of Berberis aristata as secondary metabolites. Animals treated with 4% w/w formulation demonstrated considerable wound contraction, epithelization time, and wound index in the excision model. In contrast, to control and standardize the concentrations of hydroxyproline, total amino acids, and DNA in recovering tissue were higher. At 4% w/w extract formulation, the parameters studied indicated a substantial result. Berberine and tetrahydropalmatine, active metabolites which are present in the ethanolic extract of Berberis aristata, were found to be responsible for wound healing. Based on ligand interactions, the findings verified Berberis aristata ethnomedicinal claim in a wound healing capacity.

A multicenter retrospective case-cohort study on the prevalence of incisional morbidities in late pregnant mares following exploratory celiotomy (2014-2019): 579 cases

OBJECTIVE

To report the prevalence and risk factors for incisional morbidities in late pregnant and nonpregnant/early pregnant control mares following colic surgery.

DESIGN

Multicenter, retrospective, cohort study from January 2014 to December 2019.

SETTING

Two university teaching hospitals and 1 private referral center.

ANIMALS

Five hundred and seventy-nine fillies and mares ≥2 years old that underwent celiotomy. Pregnant mares (n = 54) were >240 days in gestation from the last known breeding date and were compared to control females (n = 525) undergoing colic surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Morbidity rates were not different between mare groups with 56% of pregnant mares and 51% of control mares reporting at least 1 morbidity. Incisional swelling was the most common reported complication in both groups. Incisional swelling was associated with shorter hospital stays (odds ratio [OR], 0.18; P < 0.01), and drainage was associated with a longer hospital stay (OR, 1.27; P ≤ 0.01) and with use of an abdominal bandage (OR, 4.4; P < 0.01). Herniation was associated with hypercapnia under anesthesia (OR, 1.1; P = 0.048), previous abdominal surgery (OR, 8.3; P = 0.003), and with use of an abdominal bandage (OR, 56; P = 0.006). Body wall dehiscence was associated with longer hospital stay (OR, 1.2; P < 0.01). Nonsurvival was higher in pregnant mares (13%) compared to control mares (5%; P = 0.02).

CONCLUSIONS

The prevalence of incisional morbidities did not differ between pregnant and control mares undergoing colic surgery. Several factors were associated with incisional morbidities, including the duration of surgery and anesthesia, anesthetic variables, abdominal bandage use, previous ventral abdominal incision, and longer duration of hospitalization.

Omega Flap Technique: Revisiting Conventional Wisdom

Various surgical techniques have been described for the release of syndactylized fingers. In our experience, the omega flap technique, which includes a dorsal truncated flap and an anchor incision on the volar side, stands out as a good technique to release syndactyly. Incidentally, in symbrachydactyly also, the fused digits can be released using this technique. Despite this, we could find no reference in the recent years. We would like to stress the ease and importance of this technique, hoping many practicing hand surgeons will benefit from this. Our purpose was to revisit this technique and expose it to the younger generation of hand surgeons. We have operated on 20 cases of syndactyly of different types-simple, compound, and complex-and 5 cases of symbrachydactyly. In all cases, the omega flap on the dorsum and anchor incision on the volar aspect of the finger forming 2 lateral palmar flaps were used. The release of syndactyly was satisfactory in all patients. There was no flap necrosis. None of these cases have required secondary surgery because the primary releases were adequate. Release of syndactyly had been a problem for centuries. Awareness of the disability was insufficient in earlier days; currently, they seek early medical care. The release should be complete. These children must be able to achieve the form and function of the hand, and additionally precision to work. We believe that the use of omega flap and anchor flap is a good procedure for syndactyly release.

Keratome, a Better Alternative Scalpel to No. 15 Blade for Finer Incision-Randomized Control Trial

Background  Scalpel is the most common and oldest instrument used by surgeons for incision and to perform the surgery. A lot of improvement has occurred in the design of scalpel from the flint knife to the modern Bard-Parker handle with blades. The quest for improvement and finding a better instrument is neverending. In this study, we present an alternative scalpel to the no. 15 blade most commonly used by plastic surgeons.

Material and Methods  Consultants and residents in plastic surgery department used a no.15 blade and a 15-degree straight keratome on randomly selected patients and used subjective numerical rating scale to assess the ease of incision and dissection. The data were collected and statistically analyzed.

Results  In this study, 89 patients were included out of which 68 cases were operated by the consultants and 21 cases were operated by residents. The average score of ease of incision using a no. 15 blade by the consultants was 6.52 and by the residents was 6.125. The average score of ease of incision using a 15-degree straight keratome by the consultants was 8.74 and by the residents was 8.84. p -Value was statistically significant when no. 15 blades and 15-degree straight keratome were compared.

Conclusion  15-degree straight keratome is an excellent scalpel that can be used in preference to no. 15 blade as it is difficult to use.

Comparing Dermabond PRINEO versus Dermabond or staples for wound closure: a randomized control trial following total shoulder arthroplasty

BACKGROUND

The method of surgical incision closure after total shoulder arthroplasty is an important factor to consider, as it affects operating room time, procedure cost, cosmetic outcomes, and patient satisfaction. The optimal method of wound management is unknown, but should be cost-effective, reproducible, and provide a reliable clinical result. This study aimed to compare the following wound closure methods after total shoulder arthroplasty: staples, Dermabond, and Dermabond PRINEO. We hypothesized that wound closure time for Dermabond PRINEO would be faster than Dermabond and comparable to that of staples, and Dermabond PRINEO would be more cost-effective than Dermabond and staples, and provide equal or superior closure outcomes to Dermabond and staples.

METHODS

A randomized, prospective clinical trial comparing wound closure time and cost for 2 surgeons' traditional technique with that of Dermabond PRINEO was conducted. This study included at least 18 subjects in each group. Surgeon 1's patients were randomized to traditional Dermabond or Dermabond PRINEO, whereas surgeon 2's patients were randomized to staples or Dermabond PRINEO. Cosmetic outcomes and satisfaction scores were collected at 6 weeks and 3 months, postoperatively. Incisions were photographed, at both the 6-week and 3-month visits, and subsequently evaluated by a plastic surgeon blinded to the treatment method.

RESULTS

The wound closure time for surgeon 1 was significantly faster for Dermabond PRINEO vs. Dermabond, and surgeon 2 closed significantly faster with staples vs. Dermabond PRINEO. The mean cost of closure was significantly less with Dermabond PRINEO compared with Dermabond, whereas the mean cost of staples was significantly less than Dermabond PRINEO. For both surgeons 1 and 2, there were no significant differences in patient satisfaction at 6 weeks or 3 months. In addition, the wound closure methods did not produce differing cosmetic outcomes.

CONCLUSIONS

Although significant, the closing time for each method did not differ by a clinically relevant amount. Staples were the most cost-effective closing method, followed by Dermabond PRINEO. As neither method was superior over the other in terms of patient satisfaction, adverse events, and cosmetic outcomes, cost-effectiveness may be the greatest differentiator between the 3 methods.

Evaluation of Wound Healing and Anti-Inflammatory Activity of Hydroalcoholic Leaf Extract of Clematis simensis Fresen (Ranunculaceae)

Introduction

Clematis simensis is one of the most widely used medicinal plant for the treatment of wound traditionally. However, its claim was not scientifically tested, the current study therefore assessed the anti-inflammatory and wound healing properties of 80% methanol leaf extract of C. simensis.

Methods

The dried and powdered leaf of C. simensis was macerated with 80% methanol. The topical ointment was then made in two concentrations (5% and 10% w/w), and two models, excision and incision, were used to test the extract's capacity to treat wounds in mice. In addition, anti-inflammatory test was also conducted using carrageenan-induced hind paw edema model in three doses (100, 200, and 400 mg/kg) in rats. The DPPH test was used to determine the extract's anti-oxidant properties where ascorbic acid was used as standard agent.

Results

When wounds were treated with ointments containing 5% and 10% (w/w) extract, the rate of wound contraction, the length of time it took for the epithelium to form, and the strength of the skin to break were all significantly increased (p < 0.05). There was no discernible difference in wound healing activity between the 10% (w/w) and 5% (w/w) extracts. Moreover, they had also similar impact as that of the positive control nitrofurazone in wound healing activity. Compared to the negative control, C. simensis extract considerably (p < 0.01-p < 0.001) reduced inflammation. The extract also demonstrated antioxidant activity with IC50 values of 0.7 mg/mL for the extract and 1.04 mg/mL for ascorbic acid, respectively.

Conclusion

Overall, it is plausible to draw the conclusion that C. simensis 80% methanol extract possesses wound healing activity, perhaps as a result of its anti-inflammatory and antioxidant effects.

Is the facial nerve at risk following surgical correction of mandibular condylar fracture: A systematic review and meta-analysis

To review the literature on the effect of different surgical approaches on facial nerve injuries. The present systematic review addresses the following focus question: Is the facial nerve at risk following surgical correction of mandibular condylar fracture? Electronic and manual literature searches were conducted on databases:PubMed, ScienceDirect and Google scholar,Cochrane and clinicaltrials.gov for studies published until July 2020 to collect information about the effect of different surgical approaches on facial nerve injuries. Systematic literature review was performed following the prisma guidelines to identify studies. Quantitative retrospective and prospective studies,controlled trials,controlled clinical trials were included;case reports and review articles were excluded from this systematic review. 1500 articles published till July 2020 was identified. 116 articles met inclusion criteria. After applying exclusion criteria seven articles were shortlisted. The level of heterogeneity was observed to be less than 50%, between all parameters for all studies making publication bias to be minimum. On comparing various studies statistically using Z-test for all parameters,it was observed that level of significance was significant for various findings like Displacement/Dislocation of fracture and transient facial nerve weakness was found to be statistically significant between all studies (p-value <0.05). Odd ratio, relative ratio and 95% CI was derived for all parameters recorded for various studies. Due to less number of subjective studies, and variability in study designs and lack of reporting on confounding factors,definitive conclusions on effect of various surgical approaches on facial nerve injury cannot be drawn Future well-designed long-term randomized controlled trials are necessary to reveal the necessary correlation between both the parameters.

Postsurgical Latent Pain Sensitization Is Driven by Descending Serotonergic Facilitation and Masked by µ-Opioid Receptor Constitutive Activity in the Rostral Ventromedial Medulla

Following tissue injury, latent sensitization (LS) of nociceptive signaling can persist indefinitely, kept in remission by compensatory µ-opioid receptor constitutive activity (MORCA) in the dorsal horn of the spinal cord. To demonstrate LS, we conducted plantar incision in mice and then waited 3-4 weeks for hypersensitivity to resolve. At this time (remission), systemic administration of the opioid receptor antagonist/inverse agonist naltrexone reinstated mechanical and heat hypersensitivity. We first tested the hypothesis that LS extends to serotonergic neurons in the rostral ventral medulla (RVM) that convey pronociceptive input to the spinal cord. We report that in male and female mice, hypersensitivity was accompanied by increased Fos expression in serotonergic neurons of the RVM, abolished on chemogenetic inhibition of RVM 5-HT neurons, and blocked by intrathecal injection of the 5-HT3R antagonist ondansetron; the 5-HT2AR antagonist MDL-11 939 had no effect. Second, to test for MORCA, we microinjected the MOR inverse agonist d-Phe-Cys-Tyr-D-Trp-Arg-Thr-Pen-Thr-NH2 (CTAP) and/or neutral opioid receptor antagonist 6β-naltrexol. Intra-RVM CTAP produced mechanical hypersensitivity at both hindpaws; 6β-naltrexol had no effect by itself, but blocked CTAP-induced hypersensitivity. This indicates that MORCA, rather than an opioid ligand-dependent mechanism, maintains LS in remission. We conclude that incision establishes LS in descending RVM 5-HT neurons that drives pronociceptive 5-HT3R signaling in the dorsal horn, and this LS is tonically opposed by MORCA in the RVM. The 5-HT3 receptor is a promising therapeutic target for the development of drugs to prevent the transition from acute to chronic postsurgical pain.SIGNIFICANCE STATEMENT Surgery leads to latent pain sensitization and a compensatory state of endogenous pain control that is maintained long after tissue healing. Here, we show that either chemogenetic inhibition of serotonergic neuron activity in the RVM or pharmacological inhibition of 5-HT3 receptor signaling at the spinal cord blocks behavioral signs of postsurgical latent sensitization. We conclude that MORCA in the RVM opposes descending serotonergic facilitation of LS and that the 5-HT3 receptor is a promising therapeutic target for the development of drugs to prevent the transition from acute to chronic postsurgical pain.

Two-Incision Approach for Hypoglossal Nerve Stimulator Placement: A Single Institution Assessment

OBJECTIVE(S)

Upper airway stimulator (UAS) placement is a treatment for obstructive sleep apnea (OSA) with few complications and low morbidity. UAS placement has traditionally been performed using a three-incision approach, however, it has been implanted using a two-incision approach. This approach could significantly decrease operation time without a difference in postoperative complications, demonstrating its safety and feasibility for UAS placement. The objective was to assess operative time and complication rate in the two-incision approach for UAS placement compared to the three-incision approach.

STUDY DESIGN

Retrospectively reviewed.

METHODS

Patients who underwent UAS placement using the two- or three-incision approach at a single academic institution from November 2014 to June 2021 were retrospectively reviewed. The two-incision approach did not include the incision at the mid-axillary line. Main outcome measures included operation time and complication rates.

RESULTS

Three-hundred forty-eight patients underwent UAS placement. The three-incision approach demonstrated an average operation time of 143.3 minutes whereas the two-incision approach averaged 129.4 minutes (P < .001). There was no significant difference in rate of postoperative complications between the two- and three-incision cohorts including pneumothorax (0% vs. 0.4%, P > .99), patient-reported discomfort (5.6% vs. 6.5%, P > .99), activity restriction (0% vs. 1.4%, P > .50), and incisional pain (0.0% vs. 1.0%, P > .99). No patients experienced incision site bleeding or infection. The two-incision approach was associated with decreased rate of revision surgery (0.0% vs. 5.4%, P = .048).

CONCLUSION

The UAS two-incision approach proved to have a significantly shorter operative time without an increase in complications as compared to the three-incision approach. This approach is a safe and feasible option.

LEVEL OF EVIDENCE

III Laryngoscope, 2022.

Multiple plaque incisions with or without grafting for Peyronie's disease

Objectives

To assess novel surgical techniques in management of Peyronie's disease.

Subjects

Forty-three men underwent corrective surgery using either partial plaque incision and nongraft (PPING) or multiple plaque incisions and graft (MPIG). The technique used was determined intra-operatively. Patients were assessed at baseline and follow-up based on Peyronie's disease questionnaire patient-reported outcome measure (PDQ-PROM) and erectile function.

Results

The two groups were well matched in age and erectile function. At baseline MPIG group had greater deformity and poorer patient-reported outcome. Penile curvature improved from 67.9° to 10.5° in the PPING group and 77.9° to 7.1° with MPIG. PDQ-PROM improved from 29 to 13 in those who underwent PPING and 38.5 to 17.6 in those undergoing MPIG. Erectile function was preserved in both groups.

Conclusions

These novel surgeries are effective in restoring penile shape and length while preserving erectile function. This is reflected in improved patient-reported outcomes. These findings should be verified by multi-institutional study.

ABNORMAL CORNEAL LESION FOLLOWING CATARACT SURGERY; A CORNEAL PYOGENIC GRANULOMA? A CASE REPORT

BACKGROUND

Description of an abnormal corneal lesion as a complication of a clear corneal incision in cataract surgery.

CASE PRESENTATION

A 55-year-old woman presented, complaining of right eye pain and redness for 6 months, which started 1 month after her uncomplicated cataract surgery. On gross examination, the bulbar conjunctiva was hyperemic and a vascularized salmon-pink nodule with a smooth surface was noted over the supratemporal region of the cornea, just anterior to the previous superior corneal incision, with superficial feeder vessels originating from the adjacent conjunctiva toward the lesion. The lesion was removed and histopathological examination revealed an inflammatory tissue containing inflammatory cells and capillaries within a background of fibrotic tissue throughout the lesion.

CONCLUSIONS

Reactive fibrovascular nodules are rare corneal lesions following corneal trauma and vascularization, including a clear corneal cataract surgery incision. Ophthalmologists may encounter these lesions during postoperative visits and should be familiar with their appearance and management.

Plant-based Natural Products for Wound Healing: A Critical Review

Wound healing is an intricate process consisting of four overlapping phases, namely hemostasis, inflammation, proliferation, and remodelling. Effective treatment of wounds depends upon the interaction of appropriate cell types, cell surface receptors, and the extracellular matrix with the therapeutic agents. Several approaches currently used for treating wounds, such as advanced wound dressing, growth factor therapy, stem cell therapy, and gene therapy, are not very effective and lead to impaired healing. Further, repeated use of antibiotics to treat open wounds leads to multi- drug resistance. Today there is considerable interest in plant-based drugs as they are believed to be safe, inexpensive, and more suitable for chronic wounds. For example, a large number of plant- based extracts and their bioactive compounds have been investigated for wound healing. In recent years the structural and mechanistic diversity of natural products have become central players in the search for newer therapeutic agents. In the present review, a thorough critical survey of the traditionally used plant-based drugs used worldwide for wound healing with special reference to the natural products/bioactive compounds isolated and screened is presented. It is hoped that this review will attract the attention of the research community involved in newer drug design and development for wound healing.

Surgical success of 'W' shaped incision versus Tear Trough incision in External Dacryocystorhinostomy

PURPOSE

To compare surgical success (cosmetic, anatomical & functional) of 'W' shaped incision versus tear-trough incision in external dacryocystorhinostomy (eDCR).

METHODS

In a prospective study (November 2018 - March 2020), 61 eyes of chronic dacryocystitis underwent eDCR randomized into group T (30 eyes) & group W (31 eyes). The functional and objective cosmetic assessment was done at 3 months using Munk's and Devoto's scores respectively. The subjective cosmetic evaluation was done using a questionnaire. Grades 0-1 were considered the cosmetic and functional success after assessing the respective scores. The patent lacrimal passage was defined as anatomical success.

RESULTS

Mean age was 40.1 ± 14.9 years with female preponderance. Intraoperative skin flap button-holing & reversible darkening of their apices were specific complications of Group W. In the early postoperative period, lid edema & epiphora were significantly more in group T (p < 0.05). The functional success rate in group T and W was 93.3% and 93.5%, respectively (p = 0.53). There was a 100% anatomical success rate in group T whereas 96.8% in group W (p = 0.51). The subjective cosmetic success rate was 83.3% in group T and 80.6% in group W (p = 0.78) while objective cosmetic success rate was 63.3% and 67.7% in group T and group W, respectively (p = 0.72).

CONCLUSION

Surgical success in terms of cosmetic, anatomical & functional outcomes of W-shaped incision were comparable to the conventional Tear trough incision.

Defining the decision-to-delivery interval at caesarean section: narrative literature review and proposal for standardisation

The decision-to-delivery interval is a widely used term at non-elective caesarean section. While the definition may appear self-evident, there is no universally agreed consensus about when this period begins and ends. We reviewed the literature for original research utilising the terms 'decision-to-delivery', 'decision-to-incision' or 'incision-to-delivery' and examined definitions used for decision, delivery, incision, as well as any additional time intervals that were assessed. Our analysis demonstrated an inconsistent non-standardised approach to defining these intervals, which might have clinical practice and medicolegal ramifications. We propose that the decision-to-delivery interval should be defined as follows: the interval between the time at which the senior obstetrician makes the decision that a caesarean section is required and the time at which the fetus (or first fetus in the case of multiples) is delivered. The decision time should ideally be recorded contemporaneously in the medical notes or partogram.

Midline versus anterolateral incisions for total knee arthroplasty-a systematic review and analysis of the angiosomes of the knee

INTRODUCTION

The most common incision for total knee arthroplasty is the anterior midline incision; however, it is commonly associated with lateral knee numbness, kneeling difficulties and restricted flexion range. We sought to review the literature regarding the neurovascular supply and angiosomes over the anterior knee, and evaluate the anterolateral incision as a viable alternative for knee arthroplasty.

METHODS

A systematic review of the literature was performed searching PUBMED, MEDLINE and EMBASE to evaluate the incisions available for total knee arthroplasty with respect to neurological function, kneeling ability and complications.

RESULTS

Ten studies were identified evaluating midline or anterolateral incisions for total knee arthroplasty, with a total of 664 knees for analysis. Mean patient age was 68 years (45-88), and average length of followup was 1 year. A total of 586 had an anterior midline incision and 78 had an anterolateral incision. A total of 62% of anterior midline incisions sustained altered sensation compared to 15% (12/78) of anterolateral incisions (p < 0.0001). Incision length was similar in both groups (19.8 cm midline vs. 20.8 cm anterolateral). Wound dehiscence was not significantly different between the two groups being 8.3% for midline incisions, and 2.5% for anterolateral incisions (p = 0.153). Kneeling ability was reported in two studies which reported an improved ability to kneel with an anterolateral incision.

CONCLUSIONS

The lateral parapatellar incision respects the neurovascular anatomy of the knee and offers a significant reduction in sensory changes, better kneeling ability and similar rates of wound problems to a standard midline incision and should be considered as a viable alternative for knee arthroplasty.

Single Dose of N-Acetylcysteine in Local Anesthesia Increases Expression of HIF1α, MAPK1, TGFβ1 and Growth Factors in Rat Wound Healing

In this study, we aimed to investigate the influence of N-acetylcysteine (NAC) on the gene expression profile, neoangiogenesis, neutrophils and macrophages in a rat model of incisional wounds. Before creating wounds on the backs of 24 Sprague-Dawley rats, intradermal injections were made. Lidocaine-epinephrin solutions were supplemented with 0.015%, 0.03% or 0.045% solutions of NAC, or nothing (control group). Scars were harvested on the 3rd, 7th, 14th and 60th day post-surgery. We performed immunohistochemical staining in order to visualize macrophages (anti-CD68), neutrophils (anti-MPO) and newly formed blood vessels (anti-CD31). Additionally, RT-qPCR was used to measure the relative expression of 88 genes involved in the wound healing process. On the 14th day, the number of cells stained with anti-CD68 and anti-CD31 antibodies was significantly larger in the tissues treated with 0.03% NAC compared with the control. Among the selected genes, 52 were upregulated and six were downregulated at different time points. Interestingly, NAC exerted a significant effect on the expression of 45 genes 60 days after its administration. In summation, a 0.03% NAC addition to the pre-incisional anesthetic solution improves neovasculature and increases the macrophages' concentration at the wound site on the 14th day, as well as altering the expression of numerous genes that are responsible for the regenerative processes.

N-Acetylcysteine Added to Local Anesthesia Reduces Scar Area and Width in Early Wound Healing-An Animal Model Study

The aim of the study was to evaluate if a pre-incisional N-acetylcysteine (NAC) treatment altered the process of wound healing in a rat model. The dorsal skin of 24 Sprague-Dawley rats was incised in six locations. Before the incisions were made, skin was injected either with lidocaine and epinephrine (one side) or with these agents supplemented with 0.015%, 0.03%, or 0.045% NAC (contralaterally). Photographic documentation of the wound healing process was made at 11 time points. Rats were sacrificed 3, 7, 14, or 60 days after incision to excise scars for histological analysis. They included: Abramov scale scoring, histomorphometry analysis, and collagen fiber arrangement assessment. Skin pretreated with 0.03% NAC produced the shortest scars at all analyzed time points, though this result was statistically insignificant. At this NAC concentration the scars had smaller areas on the third day and were narrower on the day 4 compared with all the other groups (p < 0.05). On day 7, at the same concentration of NAC, the scars had a higher superficial concentration index (p = 0.03) and larger dermal proliferation area (p = 0.04). NAC addition to pre-incisional anesthetic solution decreased wound size and width at an early stage of scar formation at all concentrations; however, with optimal results at 0.03% concentration.

Bacterial adhesion inhibitor prevents infection in a rodent surgical incision model

Surgical site infection risk continues to increase due to lack of efficacy in current standard of care drugs. New methods to treat or prevent antibiotic-resistant bacterial infections are needed. Multivalent Adhesion Molecules (MAM) are bacterial adhesins required for virulence. We developed a bacterial adhesion inhibitor using recombinant MAM fragment bound to polymer scaffold, mimicking MAM7 display on the bacterial surface. Here, we test MAM7 inhibitor efficacy to prevent Gram-positive and Gram-negative infections. Using a rodent model of surgical infection, incision sites were infected with antibiotic-resistant bioluminescent strains of Staphylococcus aureus or Pseudomonas aeruginosa. Infections were treated with MAM7 inhibitor or control suspension. Bacterial abundance was quantified for nine days post infection. Inflammatory responses and histology were characterized using fixed tissue sections. MAM7 inhibitor treatment decreased burden of S. aureus and P. aeruginosa below detection threshold. Bacterial load of groups treated with control were significantly higher than MAM7 inhibitor-treated groups. Treatment with inhibitor reduced colonization of clinically-relevant pathogens in an in vivo model of surgical infection. Use of MAM7 inhibitor to block initial adhesion of bacteria to tissue in surgical incisions may reduce infection rates, presenting a strategy to mitigate overuse of antibiotics to prevent surgical site infections.

A proteome signature for acute incisional pain in dorsal root ganglia of mice

ABSTRACT

After surgery, acute pain is still managed insufficiently and may lead to short-term and long-term complications including chronic postsurgical pain and an increased prescription of opioids. Thus, identifying new targets specifically implicated in postoperative pain is of utmost importance to develop effective and nonaddictive analgesics. Here, we used an integrated and multimethod workflow to reveal unprecedented insights into proteome dynamics in dorsal root ganglia (DRG) of mice after plantar incision (INC). Based on a detailed characterization of INC-associated pain-related behavior profiles, including a novel paradigm for nonevoked pain, we performed quantitative mass-spectrometry-based proteomics in DRG 1 day after INC. Our data revealed a hitherto unknown INC-regulated protein signature in DRG with changes in distinct proteins and cellular signaling pathways. In particular, we show the differential regulation of 44 protein candidates, many of which are annotated with pathways related to immune and inflammatory responses such as MAPK/extracellular signal-regulated kinases signaling. Subsequent orthogonal assays comprised multiplex Western blotting, bioinformatic protein network analysis, and immunolabeling in independent mouse cohorts to validate (1) the INC-induced regulation of immune/inflammatory pathways and (2) the high priority candidate Annexin A1. Taken together, our results propose novel potential targets in the context of incision and, therefore, represent a highly valuable resource for further mechanistic and translational studies of postoperative pain.

A Painful Beginning: Early Life Surgery Produces Long-Term Behavioral Disruption in the Rat

Early life surgery produces peripheral nociceptive activation, inflammation, and stress. Early life nociceptive input and inflammation have been shown to produce long-term processing changes that are not restricted to the dermatome of injury. Additionally stress has shown long-term effects on anxiety, depression, learning, and maladaptive behaviors including substance abuse disorder and we hypothesized that early life surgery would have long-term effects on theses complex behaviors in later life. In this study surgery in the rat hindpaw was performed to determine if there are long-term effects on anxiety, depression, audiovisual attention, and opioid reward behaviors. Male animals received paw incision surgery and anesthesia or anesthesia alone (sham) at postnatal day 6. At 10 weeks after surgery, open field center zone entries were decreased, a measure of anxiety (n = 20) (P = 0.03) (effect size, Cohen's d = 0.80). No difference was found in the tail suspension test as a measure of depression. At 16-20 weeks, attentional performance in an operant task was similar between groups at baseline and decreased with audiovisual distraction in both groups (P < 0.001) (effect size, η² = 0.25), but distraction revealed a persistent impairment in performance in the surgery group (n = 8) (P = 0.04) (effect size, η² = 0.13). Opioid reward was measured using heroin self-administration at 16-24 weeks. Heroin intake increased over time in both groups during 24-h free access (P < 0.001), but was greater in the surgery group (P = 0.045), with a significant interaction between time and treatment (P < 0.001) (effect size, Cohen f ² = 0.36). These results demonstrate long-term disruptions in complex behaviors from surgical incision under anesthesia. Future studies to explore sex differences in early life surgery and the attendant peripheral neuronal input, stress, and inflammation will be valuable to understand emerging learning deficits, anxiety, attentional dysfunction, and opioid reward and their mechanisms. This will be valuable to develop optimal approaches to mitigate the long-term effects of surgery in early life.

Implications of comparative ventral body wall histology on selection of abdominal surgical approach and closure in 12 species of fish

A ventral midline surgical approach for fish celiotomy is commonly performed in veterinary clinical medicine and research, although the relevant ventral body wall anatomy of many fish species is not well documented. Histological evaluation of tissue samples from the ventral body wall of 12 fish species was performed to provide a reference for surgical approach and closure decisions. The width between muscle bundles running parallel to the long axis and total thickness of tissue layers varied among species. An appreciable space between longitudinal muscles of the ventral body wall and a lack of muscle, vessels and nerves on midline in all species examined supports recommendations of ventral midline incisions to spare important structures. Dense connective tissue consistent with an aponeurosis between musculature along the ventral body wall was not observed in any species evaluated. Connective tissue was concentrated within the dermis of all species evaluated, with an additional layer of collagen along the coelomic membrane in Russian sturgeon Acipenser gueldenstaedtii, koi Cyprinus carpio, goldfish Carassius auratus, black drum Pogonias cromis, black seabass Centropristis striata, tomtate Haemulon aurolineatum and scup Stenotomus caprinus. A sufficiently wide space on ventral midline for practical targeting during the surgical approach is present in A. gueldenstaedtii, C. carpio, striped bass Morone saxatilis, H. aurolineatum, P. cromis, rainbow trout Oncorhynchus mykiss and brown trout Salmo trutta. Sand perch Diplectrum formosum, C. auratus, S. caprinus, grey triggerfish Balistes capriscus and black sea bass Centropristis striata have a negligible space between longitudinal muscles on midline. The variation in ventral body wall structure observed in this study helps inform surgical decision making for celiotomy incision and closure in these species.

Comparison of ultrasound-guided puncture drainage and incision drainage for deep neck abscess

Background

Deep neck space abscess is a common disease in otolaryngology-head, and neck surgery emergencies that result in significant morbidity with potential mortality. Traditional incision drainage with antibiotics is widely accepted worldwide. Recent studies have shown that ultrasound-guided drainage is an effective strategy and is less invasive for patients. The present study aimed to explore the difference between puncture and drainage guided by B-ultrasound and traditional surgical incision in treating deep neck space abscess.

Methods

A total of 60 patients with deep neck abscess were enrolled in the present study; 43 were distributed to the B-ultrasound puncture drainage group and 17 to the incision drainage group. Clinical data were collected, and differences between the 2 treatment options were compared.

Results

There were no differences in patients' systemic illness, age, and clinical features (diameter of an abscess, amount of drainage in first 3 days, and body temperature). The cure rate of both groups was 100%; the number of hospitalization days of the B-ultrasound-guided puncture group (8 days) was significantly less than that of the incision drainage group (10.8 days).

Conclusions

Puncture drainage of neck abscess guided by B-ultrasound is a safe and effective treatment method and can reduce the patient's hospital stay.

Clinical comparison of single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures: A randomized controlled trial

PURPOSE

The purpose of this study was to clinically compare the single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures.

METHODS

In total, 93 patients were enrolled, and the mean follow-up was 15 months (range 12-19 months). The patients treated for open reduction and internal fixation were randomly classified into two groups based on the approach used: 45 patients were treated using the single-incision approach (group 1) and 48 patients were treated using the dual-incision approach (group 2). In these two groups, operation time, discharge time, postoperative complications, and ankle function evaluations (Olerud-Molander Ankle Score) were compared between the two groups.

RESULTS

There were no significant differences in the mean operation time (98.2 ± 18.5 vs. 103.6 ± 19.3), discharge time (11.1 ± 3.9 vs. 12.5 ± 5.7), overall surgical complication rates (9/45 vs. 15/48), or ankle function between the two groups (p > 0.05). However, the rate of soft tissue-related complications, such as skin slough, infection, nonunion, and delayed union, was significantly lower in group 1 (5/45) than in group 2 (14/48) (p < 0.05).

CONCLUSION

The two incision approaches were found to have similar clinical outcomes. However, with regard to soft tissue conservation, the single-incision approach was superior to the dual-incision and maybe a reliable alternative.

Longitudinal versus transverse incision for common femoral artery exposure: a systematic review and meta-analysis

BACKGROUND

A longitudinal or a transverse incision is routinely used for common femoral artery (CFA) exposure. Some believe a transverse incision is associated with a lower incidence of postoperative complications. We performed a systematic review and meta-analysis to evaluate the risk of postoperative surgical site infection, lymphatic complications, wound dehiscence and haematoma formation when using a longitudinal or transverse incision for CFA exposure.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were adhered to. We searched various databases such as MEDLINE via PubMed and Embase for relevant studies from inception till 31 May 2020. Relevant search terms such as 'longitudinal', 'transverse', 'vertical', 'horizontal', 'femoral', 'incision' were used. We included both randomized controlled trials and case-controlled studies, and extracted data related to study characteristics and postoperative complications. We assessed risk of bias using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. A random-effects meta-analysis was performed to obtain the pooled proportions and risk ratios (RR) for our study outcomes.

RESULTS

We included seven studies with a total of 5922 groin incisions. A longitudinal incision was associated with a significantly higher incidence of wound infection (RR 2.93, 95% confidence interval (CI) 1.12-7.70, P = 0.03) and wound dehiscence (RR 2.87, 95% CI 1.06-7.77, P = 0.04). The risk of lymphatic complications (RR 1.09, 95% CI 0.39-3.05, P = 0.87) and wound haematoma (RR 2.85, 95% CI 0.88-9.21, P = 0.08) were similar.

CONCLUSIONS

A longitudinal incision may be associated with a higher incidence of wound infection and wound dehiscence, as compared to using a transverse incision for CFA exposure.

In vitro Antioxidant and in vivo Wound Healing Activities of the 80% Methanol Extract and Solvent Fractions of Seeds of Brassica carinata A. Braun (Brassicaceae) in Mice

Background

Brassica carinata is one of the traditional medicinal plants used in Ethiopia for the treatment of wounds and other diseases. However, the plant has not been scientifically validated, and thus the present study evaluated the in vitro anti-oxidant and the in vivo wound healing activity of the crude extract and solvent fractions of B. carinata seeds in mice.

Materials and Methods

The crude extract was prepared by maceration using 80% methanol and formulated as 5% and 10% w/w ointments for topical application. The acute dermal toxicity was performed in female albino rats based on Organization for Economic Cooperation and Development (OECD) guideline number 434. Excision and incision wound healing models were used to evaluate the wound healing activities of crude extract and solvent fractions ointments in mice. Wound healing parameters such as wound area contraction and the period of epithelialization were determined in an excision model, whereas tensile strength was determined in an incision model. Moreover, the crude extract and solvent fractions were evaluated for the free radical scavenging activities in DPPH assay.

Results

The acute dermal toxicity test showed that a limit dose of 2,000 mg/kg of 10% w/w crude extract ointment did not cause dermal toxicity in mice. In the excision wound model, the data revealed that 10% w/w ointment exhibited a significant wound contraction (from day 6 to 16, P<0.001) effect with a significant decrease in epithelization period (at day 14, P<0.001). In addition, 5% ointment of the crude extract showed a significant effect in wound contraction (from day 8 onwards, P<0.01) and epithelization period (at day 16, P<0.01). Despite all fractions being shown to promote wound healing, 10% w/w aqueous and ethyl acetate fractions showed a significant wound contraction (P<0.001) effect starting from the 4th day onwards. Besides, the maximum antioxidant activity was seen in the aqueous fraction with an IC50 value of 3.45±0.12 mg/mL.

Conclusion

The present study demonstrated that the 80% methanol extract and solvent fractions of the seeds of B.carinata possess potential wound healing and anti-oxidant effects, supporting the traditional use of the plant for wound management.

How canyons evolve by incision into bedrock: Rainbow Canyon, Death Valley National Park, United States

Incising rivers may be confined by low-slope, erodible hillslopes or steep, resistant sidewalls. In the latter case, the system forms a canyon. We present a morphodynamic model that includes the essential elements of a canyon incising into a plateau, including 1) abrasion-driven channel incision, 2) migration of a canyon-head knickpoint, 3) sediment feed from an alluvial channel upstream of the knickpoint, and 4) production of sediment by sidewall collapse. We calculate incision in terms of collision of clasts with the bed. We calculate knickpoint migration using a moving-boundary formulation that allows a slope discontinuity where the channel head meets an alluvial plateau feeder channel. Rather than modeling sidewall collapse events, we model long-term behavior using a constant sidewall slope as the channel incises. Our morphodynamic model specifically applies to canyon, rather than river-hillslope evolution. We implement it for Rainbow Canyon, CA. Salient results are as follows: 1) Sediment supply from collapsing canyon sidewalls can be substantially larger than that supplied from the feeder channel on the plateau. 2) For any given quasi-equilibrium canyon bedrock slope, two conjugate slopes are possible for the alluvial channel upstream, with the lower of the two corresponding to a substantially lower knickpoint migration rate and higher preservation potential. 3) Knickpoint migration occurs at a substantially faster time scale than regrading of the bedrock channel itself, underlying the significance of disequilibrium processes. Although implemented for constant climactic conditions, the model warrants extension to long-term climate variation.

Cesarean Section in Patients with Myomas Located on the Anterior Wall of the Cervix

In patients with uterine myomas undergoing cesarean section, the site of the uterine incision differs depending on the location, size, and number of myomas and the location of the placenta. The difficulty is particularly high when the myomas are located on the anterior wall of the cervix. In all patients, safe fetal birth is the top priority. The incision is usually made to avoid uterine myomas, and enucleation of the myomas is performed after fetal birth. However, in some patients, the fetus must be delivered after enucleating the myomas, so practice is necessary to be prepared for such cases. In this report, I explain the critical points to be noted at the time of cesarean section, especially in patients with myomas located on the anterior wall of the cervix.

Impact of timing on wound dressing removal after caesarean delivery: a multicentre, randomised controlled trial

We compared wound dressing removal at 24 hours versus 48 hours following low-risk caesarean deliveries. This multicentre, randomised, controlled study included patients 18-44 years of age with low-risk term, singleton pregnancies. The randomisation was done weekly. Scheduled caesarean deliveries without labour were included. For comparison, the Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, Stay in hospital > 14 days (ASEPSIS) score for wound healing assessment was modified. The absolute scores were obtained based on a one-day reading rather than the five-day reading used in ASEPSIS. Zero ("0") was assigned as a complete healing. Higher scores were associated with more severe disruption of healing. The patients were enrolled between March 2015 and February 2017. The demographics were not statistically different. The wound scoring was similar in the groups at discharge and first-week evaluation. At the six weeks post-surgery, the wound scoring was significantly less in the 48-hour (3.9%) versus the 24-hour group (9%; p = .002). Dressing removal at 48 hours had a lower scoring in the low-risk population with scheduled caesarean deliveries.IMPACT STATEMENTWhat is already known on this subject? Surgical dressings are used to provide suitable conditions to heal caesarean incisions. There has been a limited number of studies on the evaluation of ideal timing on wound dressing removal after a caesarean delivery. These studies concluded there are no increased wound complications with removal at six hours versus 24 hours or within or beyond 48 hours after surgery.What do the results of this study add? The postoperative removal of the wound dressing at 48 hours had a lower wound score at six weeks than the removal at 24 hours for women with uncomplicated scheduled caesarean deliveries.What are the implications of these findings for clinical practice and/or further research? Early discharge after caesarean delivery is becoming more common. Dressing removal at 24 hours versus 48 hours becomes more crucial and needs to be clarified. Besides, high-risk populations, different skin closure techniques, and patients in labour should be addressed separately.

Clinical efficacy and safety of mucosal incision-assisted biopsy for the diagnosis of upper gastrointestinal subepithelial tumors: A systematic review and meta-analysis

Background

Endoscopic ultrasound-guided fine-needle aspiration and biopsy (EUS-FNA/FNB) has been traditionally used for making a tissue diagnosis. Several newer techniques are emerging as a viable alternative to EUS-FNA/FNB, including mucosal incision-assisted biopsy (MIAB), with a view to increasing the diagnostic yield for upper gastrointestinal (GI) subepithelial tumors (SETs). We conducted a systematic review and meta-analysis to describe the overall diagnostic yield of MIAB for upper GI SETs.

Methods

Multiple electronic databases (MEDLINE, EMBASE and Google Scholar) and conference abstracts were comprehensively searched. The primary outcome of our meta-analysis was the overall diagnostic yield of the MIAB. The secondary outcome was to study complications in terms of perforation and clinically significant bleeding. The meta-analysis was performed using a DerSimonian and Laird random-effect model.

Results

Seven studies were included in the final meta-analysis, reporting a total of 159 patients (male 86, female 73) with a mean age of 58 years. The overall pooled diagnostic yield of MIAB was 89% (95% confidence interval [CI] 82.65-93.51, I ²=0.00). Histologically, GI stromal tumor was the reported diagnosis in 38.62% (95%CI 22.29-56.24, I ²=77.51%) of tumors, followed by leiomyoma 25% (95%CI 18.02-32.62, I ²=4.42%). The overall rate of clinically significant bleeding following the procedure was 5.03% (95%CI 0.36-12.86, I ²=57.43%) and no perforations were reported.

Conclusions

MIAB is a safe and effective technique for the diagnosis of upper GI SETs and can be considered as a viable alternative to EUS-FNA/FNB. MIAB can be performed during routine endoscopy and no advanced equipment is required.