Surgical Technology International 33nd Edition
New Online Studies
Online First - August 2018
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Translational Study to Standardize the Safe Use of Bipolar Forceps, LigaSure™, Sonicision™ and PlasmaBlade™ Around the Recurrent Laryngeal Nerve in Thyroid Surgery
Yishen Zhao, MD, Changlin Li, MD, Tie Wang, MD, Le Zhou, MD, PhD, Clinical Assistant Professor, Xiaoli Liu, MD, PhD, Clinical Assistant Professor, Jingwei Xin, MD, PhD, Clinical Assistant Professor, Shijie Li, MD, PhD, Hui Sun, MD, PhD, Professor, Division of Thyroid Surgery, China–Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China, Gianlorenzo Dionigi, MD, FACS, Professor, Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy
990
Purpose: We investigated the function of the recurrent laryngeal nerve (RLN) in a live porcine model during adjacent activation with bipolar forceps (BF), LigaSure™ small jaw (LSJ), Sonicision™ and PlasmaBlade™ (PB) devices.
Methods: Each of the energy-based devices (EBD) was activated for 3 seconds at different power settings at 5, 3, 2, and 1 mm from the RLN. Nerve root function and thermal spread were measured by continuous intraoperative neuromonitoring and infrared thermal imaging.
Results: BF: The EMG amplitude decreased to 87% of baseline at a standardized distance. The highest thermal reading was 120°C at 1 mm (average 80.7°C). LSJ: EMG amplitudes were 99% (5mm), 90% (3mm) and 66% (2mm) of the baseline amplitude. At 1mm, the temperatures of the RLN surface and the LSJ tip reached 80.6°C and 100.8°C, respectively. Sonicision™: Under both the minimum and maximum settings, EMG amplitudes remained above 80% of the baseline amplitude. The highest temperatures of the device tip and RLN surface were 135°C and 117.3°C, respectively, at 1 mm. PB: The temperatures of the device tip and RLN surface increased gradually with an increase in the setting (tip 38.3°C to 163.8°C; nerve 34.8°C to 46.2°C). Loss of nerve function occurred at settings 9 and 10. There were no changes in the latency profile under any of the applications.
Conclusions: RLN roots were exposed to increased temperatures when EBDs were applied at close spacing. The results suggest that these 4 EBDs are unsafe when applied at a distance of 1-3 mm from the RLN due to their effects on both EMG and temperature.
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A Retrospective Comparative Analysis of 2D Versus 3D Laparoscopy in Total Laparoscopic Hysterectomy for Large Uteri (≥ 500g)
Rakesh Sinha, MD, Senior Gynecological Endoscopic Surgeon, and Founder, Latika Chawla, DNB, MRCOG, Gynecological Endoscopic Surgeon, Shweta Raje, MD, DNB, Senior Gynecological Endoscopic Surgeon, Gayatri Rao, DGO, DNB, Senior Obstetrician and, Gynecological Endoscopic Surgeon, Women’s Hospital, Mumbai, Maharashtra, India
1051
Study objective: To evaluate the outcomes of total laparoscopic hysterectomy using 3D vision in comparison with 2D vision in women with large uteri (³500g).
Design: Retrospective analytical study
Design Classification: Canadian Task Force II-1
Setting: Tertiary referral center for advanced gynecological surgery.
Patients: Five hundred forty six women who underwent total laparoscopic hysterectomy over a period of 13 years were studied: 301 under 2D vision and 245 under 3D vision.
Interventions: Total laparoscopic hysterectomy
Measurements: Surgical time, blood loss and complications were recorded for every case in both groups.
Main Results: The duration of surgery for hysterectomy in the 3D laparoscopy group (88.01±36.95 min) was significantly shorter than that in the 2D group (112.61±42.59 min, p=.0001). Blood loss in the 500-1000g group was significantly less in the 3D group (p=.005). The total complication rates for 3D surgery (3.37 %) and 2D surgery (6.64%) were comparable (p=.25).
Conclusion: Three-dimensional laparoscopy provides stereoscopic vision and increases precision and safety. The availability of depth perception adds to the ease of surgery, especially in cases of large uteri, leading to reductions in both the duration of surgery and blood loss, which improves patient outcomes.
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Blended Learning Methods for Surgical Education
Roger Smith, PhD, Chief Technology Officer, Danielle Julian, MS, Research Scientist, Nicholson Center, Florida Hospital, Celebration, Florida, Alyssa Tanaka, PhD, Principal Investigator, Intelligent Training Division, SoarTech Inc., Orlando, Florida
1038
The emergence and maturation of the concept of blended learning in public and military education may prove equally valuable in CME surgical education and training. Creating a learner-centric environment in which multiple modes of education are encouraged, available, integrated, and accredited can increase the level of competence achieved in CME courses. This paper defines a framework for blended surgical training using principles developed for the military and it is applied in courses at a major post-graduate surgical education center.
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Technical Steps and Tips for Linear-Stapled Gastric Bypass Based on Personal Experience and the Classification of Intraoperative Complexity
Michael Korenkov, MD, Head of Department, Department of General and Visceral Surgery, Klinikum Werra-Meissner, Eschwege, Germany
924
The most commonly performed Roux-en-Y gastric bypass (RYGB) procedure is difficult and has many technical variations. The individual patient’s anatomic characteristics, like an exceptionally large left liver lobe, fatty mesentery with limited mobile Roux limb, difficulty in positioning a stapler, etc., can greatly increase the technical difficulty of this procedure. Challenging situations in laparoscopic gastric bypass surgery can be classified according to the intraoperative complexity. According to this classification scheme, all patients in laparoscopic linear-stapled gastric bypass can be classified into one of four types: Type I - ideal. Surgery is straightforward, and every operative technique is relatively routine. Type II - less-than-ideal. Some minor technical difficulties may occur; some operative techniques can be more difficult than others. Type III - problematic. Difficult, with some operative techniques considerably more difficult than others. Type IV - very difficult. Every operative step is very difficult. The goal of this article is to analyze the steps of laparoscopic linear-stapled RYGB with regard to personal experience and the classification of intraoperative complexity.
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Special Use of Intraoperative Endoscopy in Sleeve Gastrectomy: A Case Report
Francesco Frattini, MD, Surgeon, Vincenzo Pappalardo, MD, Surgeon, Davide Inversini, MD, Surgeon, Matteo Lavazza, MD, Resident, Stefano Rausei, MD, PhD, Surgeon, Giulio Carcano, MD, Full Professor, Department of Surgery, Circolo Hospital and Macchi Foundation, Varese, Italy
968
Sleeve gastrectomy is the most frequently performed operation for the treatment of morbid obesity. Even though sleeve gastrectomy is now widely standardized, it may still benefit from the use of certain devices and procedures such as intraoperative endoscopy. The use of an endoscope offers numerous advantages that can considerably reduce the morbidity and mortality of patients who undergo laparoscopic sleeve gastrectomy. This paper describes our experience with a case in which the information obtained by endoscopy allowed us to perform a real-time assessment of the location of two large gastric polyps to control the staple-line.
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Management of Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy for Morbid Obesity
Giuseppe Currò, MD, Associate Professor of Surgery, Department of Human Pathology in Adult and Evolutive Age ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy, Iman Komaei, MD, Surgeon in Training, Claudio Lazzara, MD, Surgeon in Training, Federica Sarra, MD, Surgeon in Training, Andrea Cogliandolo, MD, Associate Professor of Surgery, Giuseppe Navarra, MD, Full Professor of Surgery, Department of Human Pathology in Adult, and Evolutive Age ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy, Saverio Latteri, MD, Consulting Surgeon, Surgical Unit, Cannizzaro Hospital, Catania, Italy
1020
Purposes: Management of staple-line leaks following laparoscopic sleeve gastrectomy (LSG) is challenging and controversial. Guidelines for leak treatment are not standardized and often involve multidisciplinary management by surgical, medical and radiological methods. Herein we present our experience and proposed strategy for handling leaks after LSG.
Patients and methods: Retrospective data regarding LSG performed from April 2012 to October 2017 at the Surgical Oncology Division, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital "G. Martino", University of Messina, Italy, were reviewed. The management approaches and the surgical, endoscopic, and percutaneous procedures used were examined. Outcomes measured included the prevalence of gastric leaks, radiological features, related morbidities and mortalities, hospital stay and management.
Results: LSG was performed in 310 patients. Eight patients were managed for gastric leak within the 5-year period: 5 (1.6% overall prevalence) from our division, 3 referred from another hospital. All cases were successfully treated conservatively with combined CT/US-guided drainage using a locking pigtail catheter and endoscopic gastric stent positioning. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (Hanarostent® 24 cm; M.I. Tech, Seoul, Korea) in addition to pigtail drains (Drainage Catheter Locking Pigtail 8F/21cm; Tru-Set® Ure-Sil, Skokie, IL, USA). Complete closure of the leak was achieved in all patients. The mean time from presentation to healing was 74 days ± 37.76 (SD). None of the patients underwent remedial surgery.
Conclusion: This study presents our management strategy for leak resolution in LSG patients. Based on our results, we strongly recommend the conservative and combined management of gastric leaks following LSG by endoscopic stenting and percutaneous drainage.
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Mechanical Reinforced Terminolateral Ileo-Transverse Anastomosis: An Option After Right Hemicolectomy-A 452 Patients Study
Jordi Castellví Valls, PhD, MD, Chief of General Surgery Department, Javier Pérez Calvo, PhD, MD, Surgeon, Ana Centeno Álvarez, PhD, Resident, Verónica González Santín, PhD, Surgeon, Lorenzo Viso Pons, PhD, Head of Coloproctology Unit, Sergio Mompart García, PhD, Luis Ortiz de Zárate, PhD, Nuria Farreras Catasus, PhD, MD, Jordi Mas Jove, PhD, Vicente Fernández Trigo, PhD, MD, Domenico Sabia, PhD, Department of Colorectal Surgery, Department of Surgery, Moisés Broggi Hospital, Barcelona, Spain
1024
Introduction: Bowel reconstruction techniques after right hemicolectomy has currently been objective of review, due to the high rate of anastomotic leak. The aim of this study is to analyse our results of the mechanical reinforced terminolateral ileo-transverse anastomosis.
Materials and Methods: A prospective and descriptive study of a consecutive series of right colonic cancer cases that underwent right hemicolectomy. Mechanical reinforced terminolateral ileo-transverse anastomosis technique was carried out in all patients. Demographics, emergency or elective surgery, surgical management, postoperative complications, rate of anastomotic leak, need for surgical procedure after complication, average stay, and mortality were analysed.
Results: A total of 452 patients underwent surgery between 2010 and 2017. Of those, 40.6% were female and 59.4% were male. The average age and body mass index (BMI) was 72±11.3 years old, and 26±7.1, respectively. Elective surgery was carried out in 405 (89.6%) patients. Laparoscopic approach was used in 250 patients (61.7%) and 6% needed conversion. Only 41 patients (10.6%) had major complications (Clavien-Dindo III-IV). The rate of postoperative paralytic ileus reach was up to 13.9%. Reintervention was needed in five patients (1.1%) due to anastomotic leak and three (0.7%) of them from the elective surgery subgroup. There were 10 patients (2.2%) with postoperative gastrointestinal bleeding. The average stay was 8.2±2.8 days and late postoperative mortality in the first 30 days was 2%.
Conclusions: Mechanical reinforced terminolateral ileo-colic anastomosis is a safe technique with a low anastomotic leak rate. Although our results using this approach seem promising, postoperative paralytic ileus is still a high-rate complication.
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Near-Infrared Indocyanine Green-Enhanced Fluorescence and Minimally Invasive Colorectal Surgery: Review of the Literature
Alberto Mangano, MD, Robotic Surgery Research Specialist, Mario A. Masrur, MD, F.A.C.S., Assistant Professor of Surgery, Roberto Bustos, MD, Robotic Surgery Research Specialist, Liaohai Leo Chen, PhD, Research Visiting Professor, Eduardo Fernandes, MD, FRCS, Chief Administrative Surgical Resident, Pier Cristoforo Giulianotti, MD, FACS, Distinguished Lloyd Nyhus Professor of Surgery, Chief Division of General Minimally Invasive & Robotic Surgery, Vice-Head Department of Surgery, Director Robotic Surgery Fellowship Program, Associate Director UIC Health Science Simulation Consortium, Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, Chicago, IL
1041
Background: Leakage of the anastomosis after colonic/rectal surgery is a serious complication. One of the most important causes of anastomotic leakage is impaired vascularization. A microvascular tissue deficit is very often not intraoperatively de visu detectable under white light. Near-infrared indocyanine green (ICG)-enhanced fluorescence is a cutting-edge technology that may be useful for detecting microvascular impairment and potentially preventing anastomotic leakage.
Aim: The aim of this narrative review was to evaluate the feasibility and the usefulness of intraoperative assessment of vascular anastomotic perfusion in colorectal surgery using an indocyanine green (ICG) fluorescent tracer.
Material and methods: A PubMed/MedLine, Embase, and Scopus narrative literature review was performed, in which “colorectal surgery” and “indocyanine green” were used as key words. The inclusion criteria were 1) manuscripts written in English; 2) full text is available; 3) topic related to the use of ICG fluorescence for the assessment of tissue perfusion during laparoscopic or robotic colorectal surgery; and 4) sample: adult patients, benign or malignant disease. Exclusion criteria included 1) case reports; 2) topic not related to the use of ICG fluorescence for the evaluation of tissue perfusion during laparoscopic or robotic colorectal surgery; 3) manuscripts that focused solely on other applications of ICG technology; and 4) any study type not showing original data.
Results and Critical Discussion: The intraoperative visual assessment of tissue viability under white light may lead to an underestimation of microvascular blood flow impairment. ICG can be safely used in cases of minimally invasive colonic surgery and also low anterior resections. This technology may be useful when deciding whether to intraoperatively change a previously planned resection/anastomotic level, which could decrease theoretically the occurrence of anastomotic leakage.
Conclusions: Near-infrared ICG technology is a very useful approach. Multiple preliminary studies suggest that this technique may be used to predict anastomotic leakage. However, evaluation of the ICG signal is still too subjective. Some reliable scoring/grading parameters related to the ICG signal need to be defined. Additionally, more prospective, randomized, and adequately powered studies are required to completely reveal the true potential of this surgical technological innovation.
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Conservative Management of Chronic Anal Fissure. Results of a Case Series at 2-years Follow-up and Proposition of a New Classification
Antonio Canero, MD, PhD, Consultant General Surgeon, Carmela Rescigno, MD, General Surgeon, Francesco Giglio, MD, Consultant general surgeon, L'Azienda Ospedaliero Universitaria San Giovanni di Dio e Ruggi D'Aragona, Salerno, Italy, Vincenzo Consalvo, MD, Consultant general surgeon, Chirurgia Generale, Università degli Studi di Salerno, Salerno, Italy, Francesca D'Auria, MD, General Surgeon, Salsano Vincenzo, MD, Director of Bariatric Surgery Department, Clinique Clementvielle, Montpellier, France
1010
Background: Anal fissure is a common proctological condition that is usually defined as an anodermal ulcerative process starting from the posterior commissure to the dentate line. The objective of this study was to evaluate the resolution rate of anal fissure through the use of conservative management in patients grouped according to our newly proposed classification. A secondary purpose was to quantify the recurrence rates at 2-years follow-up in each group.
Methods: A retrospective analysis was carried out on patients in our general database. Diagnosis was based on symptoms, clinical observation, anal manometry and transanal ultrasounds. After application of inclusion and exclusion criteria, patients were assigned to different groups. Follow-up was carried out at 3, 6, 12 and 24 months.
Results: A total of 136 patients (54 female and 82 male) were included in the statistical analysis. At the end of the treatment period, all patients in groups 1 and 2 had a complete resolution of illness and a normal basal sphincterial tone, while those in groups 3 and 4 had a higher rate of recurrence at the 2-year follow-up.
Conclusion: Based on our series, we propose a definitive non-surgical management for all group 1 and 2 anal fissures according to our protocol. For groups 3 and 4, we recommend a primary non-surgical approach with follow-up. This was a retrospective study and further randomized controlled studies will be necessary to confirm our results.
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Initial Experience with Robotic Hernia Repairs: A Review of 150 Cases
Ty Kirkpatrick, DO, Minimally Invasive Surgery Fellow, Our Lady of the Lake Physician Group, Baton Rouge, Louisiana, Bethany Zimmerman, MD, Resident, Louisiana State University Health Science Center, New Orleans, Louisiana, Karl LeBlanc MD, MBA, FACS, FASMBS, Associate Medical Director, Our Lady of the Lake Physician Group, Baton Rouge, Louisiana
1050
Background: Robotic-assisted surgery has proved to be a valuable modality in specialties such as urology and gynecology and has gained wide acceptance in those fields. Its value in general surgery, however, has had a slower acceptance rate among surgeons. This study reviews my first 150 cases using the robot for one of the most common general surgery operations—the repair of hernias.
Materials and Methods: All robotic hernia cases performed by a single surgeon were documented in an Excel® (Microsoft Corporation, Redmond, Washington) spreadsheet beginning in April, 2014. Data recorded included patient diagnosis, hernia defect size, mesh type and size, console time and total operative time, as well as first assistant (fellow, resident, or none). The postoperative course was carefully reviewed through the electronic medical record to identify complications and readmissions.
Results: The average total case time was 138 minutes, while the average console time was 100 minutes. Incisional hernias made up 50.4% of the procedures, inguinal hernias—17.2%, ventral/umbilical—9.8%, parastomal—9.2%, lumbar—5.5%, hiatal—4.9%, and spigelian—2.5%. The average defect size was 48.47cm2. Complication rates were low at 5.3%, most of which were minor. There were no mortalities. There has been one known hernia recurrence.
Conclusions: This review shows that the use of the robot has proven to be safe and effective, and it has many benefits in hernia repair. One of those benefits is the ability to close the fascial defect with a running suture, thus avoiding the postoperative pain associated with transfascial sutures. The ability to intracorporeally fix a large piece of mesh to the abdominal wall that adequately and evenly covers the defect is another benefit. The high-quality three-dimensional view and the ability to articulate the instruments are well-established benefits of the robot as well. Robotic assistance also allows us to perform a minimally invasive hernia repair on large complex defects that would have otherwise been performed via an open approach.
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Three Techniques of Contained Morcellation for the Minimally Invasive Gynecologic Surgeon
James Dana Kondrup, MD, Clinical Assistant Professor, Upstate Medical Center, Syracuse, New York, Conor Grey, Medical Student 4th Year, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
984
Since 1993 (and prior, WISAP® [WISAP Medical Technology GmbH, Brunnthal, Germany] hand morcellators), laparoscopic power morcellation has been an indispensably employed technique for minimally invasive gynecologic surgery, contributing both to laparoscopic myomectomies and hysterectomies. However, the technique was highlighted with concern by the FDA for the given potential to disseminate neoplastic and non-neoplastic cells by morcellating an unexpected uterine sarcoma (Fig. 1). Given this concern, many gynecologists are either resorting to performing traditional laparotomies or risking dissemination with uncontained power morcellation techniques. The purpose of this article is to address these concerns by illustrating three techniques to perform contained power morcellation, thereby reaping the benefits of the technique without the disadvantage of possible dissemination of neoplastic cells. The techniques outlined in this article include the use of trans-abdominal mini-laparotomy manual contained morcellation, trans-vaginal manual contained morcellation, and the new Contained Tissue Extraction (CTE) System (Olympus America, Inc., Center Valley, Pennsylvania) for power morcellation.
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The Association Between Hospital Surgical Volume and the Uptake of Minimally Invasive Surgical Approach and Outpatient Setting for Hysterectomy
Emad Mikhail, MB, ChB, MD, FACOG, FACS, Assistant Professor/Minimally Invasive Gynecologic Surgeon, Stuart Hart, MD, Voluntary Faculty, University of South Florida/Morsani College of Medicine, Tampa, Florida, Papri Sarkar, MD, Resident Physician, University of South Florida/Morsani College of Medicine, Tampa, Florida, Marilyn Moucharite, MS, Research Manager, Healthcare Economics and Outcomes Research, Medtronic plc, Minneapolis, Minnesota
994
Background: There are large variations in the use of minimally invasive surgery (MIS), and outpatient hysterectomy (OP) among Medicare patients according to hospital surgical volume and geographical distribution.
Objective: To explore the changing trend in OP and MIS hysterectomy in the United States. Study Design: We used all Medicare fee-for-service claims data for 2012 and 2014 to determine the incidence of OP and MIS hysterectomy according to hospital surgical volume and geographical distribution. MIS included both laparoscopy and robotic surgery. OP procedures included only same-day discharge hysterectomies.
Results: A total of 55,562 and 53,054 hysterectomies were performed in the years 2012 and 2014, respectively. OP rate in 2014 in high-volume centers (16,828 [47.1%]) exceeded low-volume centers (136 [16%]) by 31.1% (p<0.001). Time trends between 2014 and 2012 show that a rise in OP rate was 17.7% and 7% for high- and low-volume hospitals (p<0.001), respectively. High-volume hospitals showed an increase of 3.1% (p=0.003) in MIS hysterectomy rate in 2014 (69%) as compared to 2012 (65.9%). There was no change in MIS rate among low-volume hospitals.
Conclusion: In the Medicare population, the rate of OP and MIS hysterectomy for high-volume centers is significantly different form low-volume centers. Over the years, outpatient hysterectomy is being practiced widely but an increase in MIS rate is limited to high-volume centers.
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Endometrial Ablation: Past, Present, and Future, Part II
Morris Wortman, MD, FACOG, Director and Clinical Associate Professor of Gynecology, Center for Menstrual Disorders, University of Rochester Medical Center, Rochester, New York
1052
Endometrial ablation (EA) is the most commonly performed surgical procedure for the management of abnormal uterine bleeding unresponsive to medical therapy. In well-selected subjects, EA provides a safe, inexpensive, and convenient alternative to hysterectomy with a rapid return to normal function.
The first generation of EA techniques were introduced in 1886 by Professor Sneguireff of Moscow. He was the first to apply super-heated steam to the uterine cavity to vaporize the endometrial basalis. This method—known as atmocausis—was refined by Ludwig Pincus of Danzig in 1895, and he went on to perform over 800 procedures. As the 20th century brought forth other energy sources—electricity, X-ray, radium, and even cryogenics—they were each used, in turn, to accomplish endometrial ablation. In 1981, Dr. Milton Goldrath successfully performed EA by co-locating a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser with a rod-lens hysteroscope to achieve photovaporization of the endometrium. The accomplishment of EA under direct visualization defined the second generation of EA. The challenges and risks of second-generation technology, however, were soon apparent, and though this practice continues today, it appears to be confined to a relatively small number of devoted and highly-skilled sub-specialists.
The late 1990s saw increasing interest in safe, affordable, and easily-mastered EA technology. The result was a return to blind technology but modified with a variety of features that brought unprecedented safety to EA, even permitting its selected in-office application. This third generation of EA techniques and devices has propelled the growth of EA in the 21st century.
Although much has been accomplished in the quest for safe, affordable, convenient, and easily-mastered EA, the future requires refinement of patient selection criteria, management strategies for late-onset endometrial ablation failures (LOEAFs), as well as minimally invasive methods for reducing them.
Vol 32.
Endometrial Ablation: Past, Present, and Future, Part I
Morris Wortman, MD, FACOG, Director, Center for Menstrual Disorders, Clinical Associate Professor Gynecology, University of Rochester Medical Center, Rochester, New York
987
Endometrial ablation (EA) is a commonly performed minimally invasive technique to manage intractable uterine bleeding that is unresponsive to medical therapy. It originated in ancient times when chemical astringents were used to control uterine hemorrhage associated with childbirth and a variety of other gynecologic conditions. In the late 19th century, the use of astringents and chemical cauterants gave way to the application of a variety of thermal energy technologies to cause selective destruction of the endometrium. These energy sources—steam, electricity, and even gamma rays—were applied blindly and were, by all accounts, quite effective at a time when hysterectomy was unsafe, infrequent, and generally unavailable.
With the emergence of improved optics and laser and video technology in the late 20th century, a resurgence of interest in endometrial ablation began—coinciding with a time when hysterectomy was commonly performed in developed countries. Endometrial ablation underwent a revolutionary change as physicians searched for new techniques to perform selective endometrial destruction under direct visual—hysteroscopic—control. In this first of a two-part series, we will explore the first and second generations of endometrial ablation to understand how this procedure has evolved into its present status and what issues remain to be solved.
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Extra-Thoracic Video-Assisted Thoracoscopic Surgery Rib Plating and Intra-Thoracic VATS Decortication of Retained Hemothorax
Natalie N. Merchant, BS, Medical Student, David Geffen School of Medicine at UCLA, Los Angeles, California, Osita Onugha, MD, MBA, Assistant Professor, John Wayne Cancer Institute, Santa Monica, California
1021
We report a patient who presented with multiple rib fractures after falling off a horse and was initially managed medically. Several weeks later, the patient returned to the hospital complaining of dyspnea on exertion. Physical exam revealed severe chest wall malformation and imaging revealed moderate hemothorax and complete collapse of the right lower lobe. Considering the likelihood that this patient’s multiple ribs fractures contributed to the hemothorax and trapped lung, the patient underwent surgical evacuation of the hemothorax followed by rib fixation of ribs three through six. The procedures were performed using both intra-thoracic and extra-thoracic video-assisted thoracoscopic surgery (VATS) and did not require the use of thoracotomy incision or open exposure of the thoracic cavity. This case report suggests that this operative technique is a viable option for delayed presentation of multiple rib fractures and complex sequela associated with this pathology.
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Mid- and Long-Term Outcome of Currently Available Endografts for the Treatment of Infrarenal Abdominal Aortic Aneurysm
Leonie T. Jonker, MD, Surgical Resident, Arne de Niet, MD, PhD Candidate/Surgical Resident, Ignace F. J. Tielliu, MD, PhD, Consultant/Vascular Surgeon, Clark J. Zeebregts, MD, PhD, Consultant/Vascular Surgeon/Professor, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands, Michel M. P. J. Reijnen, MD, PhD, Consultant/Vascular Surgeon, Rijnstate Hospital, Arnhem, the Netherlands
1046
Currently, there is a wide range of commercially available endografts for infrarenal abdominal aortic aneurysm (AAA) repair. Results of long-term follow up after endovascular aneurysm repair (EVAR) are limited. Thereby, the durability of these endografts and the difference between manufacturers is not fully clear.
In this review, studies with mid- and long-term results, with a minimum median follow up of 36 months per endograft, were included describing results with Cook Zenith® Flex® endograft (Cook Medical Inc., Bloomington, Indiana) (n=6), Cordis Corporate INCRAFT® (Cordis Corporation, Freemont, California) (n=1), Gore® EXCLUDER® (W.L. Gore & Associates Inc., Flagstaff, Arizona) (n=3), Medtronic Endurant™ (Medtronic plc, Santa Rosa, California) (n= 6), and Vascutek Anaconda™ (Vascutek Ltd., Inchinnan, Scotland) (n=2).
The assisted technical success varied between 83% and 100%, and the perioperative mortality, early reintervention, and early conversion rates were comparable for the studied endografts. At three-year follow up, the freedom from AAA-rupture and AAA-related death varied between 98% and 100%. The results demonstrated an increasing complication and reintervention rate over time. When adhering to the instruction for use, minor differences were seen during follow up between the endografts. Latest generation endografts continue to have good postoperative results; the reintervention-rate of 10–20% over time mandates an ongoing close patient follow up. The choice of a specific design depends on native patient anatomy and the experience of the implanting surgeon.
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Outcomes of Revision Joint Arthroplasty Due to Metal Allergy and Hypersensitivity: A Systematic Review
Julio J. Jauregui, MD, Orthopaedic Surgery Resident, Shivam J. Desai, MD, Orthopaedic Surgery Resident, Arun Hariharan, MD, Orthopaedic Surgery Resident, Farshad Adib, MD, Orthopaedic Surgeon, University of Maryland Medical Center, Baltimore, Maryland, Vaughn Hodges, MD, Resident Physician, University of California San Francisco, San Francisco, California, Jared M. Newman, MD, Orthopaedic Surgery Resident, Aditya V. Maheshwari, MD, Director, Adult Reconstruction and Musculoskeletal Oncology Divisions, SUNY Downstate Medical Center, Brooklyn, New York
1008
Background: Lower extremity total joint arthroplasty (TJA) is one of the most successful orthopaedic procedures. However, it is estimated that as many as 10% to 20% of TJAs could fail due to various well-known causes. Furthermore, metal allergy-related complications have recently gained attention as one of the potential causes of failure when the common reasons have been excluded. Reported symptoms from metal allergy can include chronic eczema, joint effusions, joint pain, and limited range of motion. Few studies have explored the outcomes of patients undergoing revisions due to allergic complications. The aim of our study is to quantitatively evaluate the outcomes of revision joint arthroplasty due to metal allergy and hypersensitivity.
Materials and Methods: A comprehensive literature search using MEDLINE (PubMed), Ovid, and Embase was systematically performed to evaluate all studies included in the literature until December 2015. The search terms used were “Arthroplasty,” “Allergy,” “Revision,” “Allergic Reaction,” and “Hypersensitivity,” and a total of 414 studies were identified. After a thorough review, five studies ultimately met the inclusion criteria and were included in the final review. This was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Results: A total of 44 total knee arthroplasty (TKA) revisions and three total hip arthroplasty (THA) revisions due to metal allergy were reported. All of the implants used during the primary procedures were cobalt chromium blends, and bone cement was used in all but three cases (93%). Allergen testing was performed using patch testing, modified lymphocyte stimulation test (mLST), or lymphocyte transformation testing (LTT) in all cases. Of the four studies which reported results, positive sensitizations were most commonly seen with nickel (87% of cases), followed by cobalt (37%) and chromium (reported in one study, ~10%). Following revision surgery, 100% of cases experienced symptomatic relief.
Conclusions: Overall, we found that properly selected patients with allergy-related symptoms can benefit from undergoing a revision TJA with replacement to components void of the offending allergen metals. Appropriate revision surgery provided universal resolution of symptoms and improved functional outcomes.
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Anterolateral Ligament of the Knee: What we Know About its Anatomy, Histology, Biomechanical Properties and Function
Thomas Neri, MD, PhD, Doctor of Surgery, Frederic Farizon, MD, Professor of Surgery, Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Saint-Priest-en-Jarez, France, EA 7424 - Inter-university Laboratory of, Human Movement Science, Université de Lyon - Université Jean Monnet, Saint Etienne, France, Sydney Orthopaedic Research Institute, Sydney, Australia, David Anthony Parker, BMedSci, MBBS, FRACS, FAOrthA, Associate Professor of Surgery, University of Sydney, Director of Research, Sydney Orthopaedic Research Institute, Sydney, Australia, Aaron Beach, PhD, Research assistant, Sydney Orthopaedic Research Institute, Sydney, Australia, Bertrand Boyer, MD, PhD, Doctor of Surgery, Department of Orthopaedic Surgery, University Hospital of Saint Etienne, Saint-Priest-en-Jarez, France
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To better control anterolateral rotational instability (ALRI) after anterior cruciate ligament reconstruction (ACLR), many recent studies have examined the anterolateral ligament (ALL). Although some inconsistencies have been reported, anatomic studies demonstrated that the ALL runs on the lateral side of the knee from the femoral lateral epicondyle area to the proximal tibia, between Gerdy’s tubercle and the fibula head. Histologic research has characterized the ALL structure, which is more than a simple capsular thickening; it shows a dense collagen core, typical bony insertions and mechanoreceptor function. An analysis of biomechanical properties suggests that the ALL is weaker than other knee ligaments. While its contributions to tibial anterior translation control and to a high grade on the Pivot-Shift test are still unclear, there is a consensus that the ALL controls tibial internal rotation. Further research will be needed to clarify the significance of ALL injuries and to gauge the value of combined ACL and ALL reconstructions.
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Influence of Soft Tissue Preservation in Total Hip Arthroplasty: A 16-Year Experience
Olivia J. Bono, BA, Clinical Research Coordinator, Chris Damsgaard, MD, Arthroplasty Fellow, Claire Robbins, PT, DPT, MS, Research Assistant, Mehran Aghazadeh, MD, Surgical Assistant, Carl T. Talmo, MD, Vice Chair for Orthopedic Research, James V. Bono, MD, Vice Chair for Orthopedics, Department of Orthopedic Surgery, New England Baptist Hospital, Boston, Massachusetts
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Background: Surgical technique in total hip arthroplasty (THA) has been a topic of debate over the last 50 years. Evidence-based studies are needed to compare one technique to another. This study investigated the outcome of the direct superior approach in primary THA as measured by patient perception of pain and recovery over a 16-year period.
Materials and Methods: We retrospectively reviewed a series of 3,357 consecutive patients who underwent primary THA by a single surgeon using the direct superior approach between 2001 and 2017. The surgical technique was modified twice during this 16-year period. The first modification (2007) consisted of piriformis tendon preservation. The second modification (2012) consisted of iliotibial band (ITB) preservation. These two modifications of the surgical technique created three different patient groups. A telephone interview regarding patient pain and recovery after each THA was conducted with 147 patients who had staged bilateral THA procedures wherein the surgical technique was modified between the first and second (contralateral) THA.
Results: Results show the addition of ITB preservation to capsular repair, with or without piriformis preservation, greatly improves the patient’s perception of pain and recovery, causing the majority of patients to prefer their ITB-preserving surgery over their ITB-sacrificing surgery. In addition, the dislocation rate over this 16-year period is 0.17%.
Conclusion: The direct superior approach to the hip results in excellent stability with a dislocation rate of 0.17%. The patient’s perception of pain and recovery is dramatically improved with preservation of the iliotibial band.
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Loss of Functional Internal Rotation Following Various Combinations of Bilateral Shoulder Arthroplasty
Jacob J. Triplet, DO, PGY-2 Orthopaedic Surgery Resident, OhioHealth Doctors Hospital, Columbus, OH, Jennifer Kurowicki, MD, Orthopaedic Surgery Research Fellow, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ, Derek D. Berglund, MD, Orthopaedic Surgery Research Fellow, Jonathan C. Levy, MD, Chief of Orthopaedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, FL, Samuel Rosas, MD, Orthopaedic Physician Scientist, Wake Forest School of Medicine, Winston-Salem, NC, Brandon J. Horn, DO, Orthopaedic Surgeon, Witham Orthopaedic Associates, Lebanon, IN
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Background: Limited internal rotation (IR) remains a concern for activities of daily living (ADLs) following bilateral shoulder arthroplasty (BSA). The purpose of this study was to evaluate the loss of the ability to perform functional IR tasks following BSA using various combinations of anatomic (TSA) and reverse (RSA) shoulder arthroplasty.
Methods: A retrospective review of an institutional shoulder-surgery database was conducted for patients who underwent BSA with any combination of TSA or RSA with at least a 2-year follow-up. IR range of motion (ROM) and individual American Shoulder and Elbow Surgeons (ASES) score and Simple Shoulder Test (SST) questions specific to IR were used to assess a patient’s ability to perform IR tasks with at least one of their shoulders.
Results: Seventy-three patients met the inclusion criteria (47 TSA/TSA, 17 RSA/RSA, and 9 TSA/RSA). Average age at surgery was 72.1 years. Average follow-up was 51.4 months. Loss of ability to wash one’s back was observed in 30.4% TSA/TSA, 33.3% TSA/RSA, and 52.9% RSA/RSA. Loss of ability to tuck in a shirt was observed in 10.6% TSA/TSA, 11.1% TSA/RSA, and 29.4% RSA/RSA. Loss of ability to manage toileting was observed in no TSA/TSA or TSA/RSA, but in 11.8% RSA/RSA. For each of the tasks, there were no significant differences in the ability to perform the task among the groups (p>0.05). Post-operative IR ROM for TSA/TSA was superior to those for TSA/RSA and RSA/RSA (p<0.01). IR ROM efficacies for both RSA/RSA and TSA/RSA were inferior to that for TSA/TSA (p<0.05).
Conclusion: Bilateral RSA patients can perform most IR tasks, and their ability to complete these tasks does not differ significantly from those in patients with other BSA.
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Cost Savings in a Surgeon-Directed BPCI Program for Total Joint Arthroplasty
Ahmed Siddiqi, DO, MBA, Resident, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, Peter B. White, BS, Medical Student, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania, William Murphy, MS, Medical Student, Harvard Medical School, Cambridge, Massachusetts, Dave Terry, MBA, CEO, Founder, Archway Health, Boston, Massachusetts, Stephen B. Murphy, MD, Orthopedic Surgeon, Assistant Professor of Surgery, Carl T. Talmo, MD, Orthopedic Surgeon, Assistant Professor of Surgery, Tufts University School of Medicine, New England Baptist Hospital, Boston, Massachusetts
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Background: There are few studies available on the savings generated and strategies employed for cost reduction in total joint arthroplasty. In this study, our organization—a group of private practices partnering with a consultant—aimed to analyze the impact of a preoperative protocol on overall cost savings. Materials and Methods: Using administrative data from the Medicare Bundled Payments for Care Improvement (BPCI) initiative, 771 consecutive total joint arthroplasty patients from 2009–2014 were compared with 408 consecutive BPCI patients from 2014–2017. The 30-day episode and Medicare part B total cost of care was analyzed. This included inpatient and post-discharge expenditure, laboratory and imaging costs, physician and ER visits, and readmission. Results: Average total episode cost declined by $3,174 or 13% from $23,925 to $20,752 (p<0.001) in the BPCI period. Readmission rate was unchanged (p=0.20), and there was a 48% reduction in the percent of patients presenting to the emergency room (p=.03). There was a decline of $2,647 (78%) in skilled nursing cost per case, which represented the majority of savings. Post-discharge imaging, laboratory test claims, postoperative emergency room visits, primary care physician (PCP) visits, and cost per episode all decreased. The decrease in PCP utilization did not result in increased medical complications or readmissions. Conclusion: Our preoperative patient-education protocol has decreased non-home discharge, unnecessary postoperative physician visits, and diagnostic testing resulting in an episode cost savings of 13%. With Advanced BPCI on the horizon, orthopedic surgeon control as the awardee of the bundle, combined with an increasing focus on patient education, will continue to lower costs and improve patient care.
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Is an Intramedullary Nail a Valid Treatment for Limb-Length Discrepancy After Bone Tumor Resection? Case Descriptions
Francesco Muratori, MD, Specialist in Orthopedics and Traumatology, Guido Scoccianti, MD, Specialist in Orthopedics and Traumatology, Giovanni Beltrami, MD, Specialist in Orthopedics and Traumatology, Davide Matera, MD, Specialist in Orthopedics and Traumatology, University of Florence, Azienda Ospedaliera Universitaria Careggi, Florence, Italy, Rodolfo Capanna, MD, Professor of Orthopedics and Traumatology, University of Pisa, Clinic of Orthopaedics and Traumatology, Pisa, Italy, Domenico Andrea Campanacci, MD, Professor of Orthopedics and Traumatology, University of Florence, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
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One of the most frequent outcomes after resection of bone tumors in children is a limb-length discrepancy. An intramedullary nail is a valid method for lengthening the limb. We report our experience with four cases of limb-length discrepancy in the lower limbs several years after the primary treatment of bone tumor resection and subsequent reconstruction. Two femoral PRECICE® nails (NuVasive, Inc., San Diego, CA) were introduced retrograde and two were introduced in an anterograde manner. All four cases healed and showed a reduction of the limb-length discrepancy, early loading, and complete bone osteogenesis. In one case, a reduction of the joint ROM recovered after release of the iliotibial band and a quadriceps release according to Judet’s arthrolysis.
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Acromioclavicular Joint Stabilisation Using the Internal Brace Principle
Paul A. Byrne, MEng, MSc, MBChB, Specialty Registrar, NHS South-East Scotland, Edinburgh, Scotland, Graeme P. Hopper, MBChB, MSc, MRCS, Specialty Registrar, Trauma and Orthopaedics, William T. Wilson, MBChB BSc(Med.Sci) MRCSEd, Specialty Registrar/ Honorary Clinical Lecturer, Gordon M. Mackay, MD, FRCS(Orth), FFSEM(UK) , Consultant Surgeon, Orthopaedics Department, Ross Hall Hospital, Glasgow, Scotland
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Introduction: Injury of the acromioclavicular joint (AC joint) is one of the most common conditions affecting the shoulder girdle in athletes, particularly in contact sports. It is generally agreed that surgical management provides superior outcomes in high-grade injuries (Rockwell Grades IV–VI), with nonoperative management preferred in low-grade injuries (Grades I–II). Controversy still exists regarding the optimal treatment for Grade III injuries, with various sources reporting quicker return to activity and reduced complications with nonoperative management, but superior long-term function and satisfaction in cases managed surgically. Mean predicted return to sporting action in surgical cases varies in the literature from four months to 9.5 months.
Case Description: This retrospective case report follows a 28-year-old male Scottish Premiership professional football player after he suffered a Grade III AC joint dislocation whilst playing in a European club match. He was managed operatively using a novel minimally invasive surgical technique using the principles of internal brace ligament augmentation.
Results: This player resumed full first-team action exactly three months post-surgery. After more than two years of follow up, he has experienced no complications or re-injury of the shoulder and has maintained his previous level of performance.
Conclusion: This case represents an exceptional recovery to high-level sporting performance. The novel repair method was key to this success in allowing early mobilisation of the shoulder and could offer improved results to high-level athletes suffering such injuries.
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Performance on a Virtual Reality DHS Simulator Correlates with Performance in the Operating Theatre
Mr. Kalpesh R. Vaghela, MBBS BSc MSc MRCS, Trauma & Orthopaedic Registrar, Percivall Pott Rotation, Mr. Joshua Lee, BSc (Hons) MBChB, MSc, FRCS (Tr & Orth), Consultant Trauma & Orthopaedic Surgeon, Mr. Kash Akhtar, MBBS, BSc, MEd, MD, FRSA, FRCS (Tr & Orth), Consultant Trauma & Orthopaedic Surgeon, Royal London Hospital, Barts Health NHS Trust, Whitechapel, London
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Introduction: Dynamic Hip Screw (DHS) fixation of neck of femur fractures is one of the most commonly performed orthopaedic trauma operations. Changes in working practices have impacted surgical training and have resulted in fewer opportunities to perform this procedure. Virtual reality (VR) simulation has been shown to be a valid means of gaining competency, efficiently and safely, without compromising patient safety. Objective: The aim of this study is to determine whether performance on a VR DHS simulator orrelates with performance in the operating theatre.
Materials and Methods: All episodes of DHS fixation of neck of femur fractures performed at Royal London Hospital, Barts Health NHS Trust, level 1 major trauma centre between January 2014 and December 2015 were identified using the hip fracture database. The primary surgeon was identified using the electronic operative notes. The intraoperative fluoroscopic images were accessed and the tip-apex distance (TAD) was measured, as well as the probability of cut-out. The surgeon then performed DHS fixation on a VR DHS simulator and the TAD achieved in theatre was correlated with the simulated TAD.
Results: Twenty-five surgeons, including six novices (core surgical trainees), 12 intermediates (specialist registrars), and seven experts (fellows and consultants), completed the study. There was no overall statistically significant difference in TAD between those achieved in the operating theatre and on the simulator for each participant (p=0.688).
Conclusion: There is no significant difference between performance on a VR DHS simulator and the operating theatre. This suggests that the simulator is excellent for training in this component of the DHS procedure, but further work is needed to assess whether training on the simulator can improve performance in the operating theatre.
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Capsular Sparing Total Hip Replacement Technique Applied with a Dual-mobility Cup to Reduce Dislocations
H. Morton Bertram III, MD, Chief Orthopaedic Surgeon, Naples Community Hospital, Naples, Florida, Megan E. Bertram, Trainee, Northern Kentucky University, Highland Heights, Kentucky, Laura Scholl, MS, Manager, Manoshi Bhowmik-Stoker, PhD, Senior Manager, Clinical Research Department, Stryker Orthopaedics, Mahwah, New Jersey, Michael T. Manley, FRSA, PHD, President, Michael T. Manley, LLC, Wyckoff, New Jersey
1025
Regardless of the surgical approach used, dislocation remains a complication following total hip replacement. In recent years, newer technologies, such as the use of large femoral heads, have reduced the rate of postoperative dislocation. The combination of such technology, together with a soft tissue repair technique, may reduce the dislocation rate even further.
A single surgeon performed 513 primary total hip replacements on 505 patients using a posterior approach utilizing a technique designed to spare the capsule. There were 257 males and 248 females. Age ranged from 39 to 92 years. Surgeries were performed from January 2012 to December 2015. Implants used were cementless dual-mobility cups and cementless femoral stems. In all cases, the posterior capsule was incised and retracted, but not excised. Following implant placement, the capsule was repaired using a fiber reinforced suture. The superior border of the capsular incision, just above the piriformis, was sutured to the superior capsule or gluteus minimus muscle. The intent of this repair was to completely incarcerate the femoral head. Patients were followed at two weeks, six weeks, three months, one year, three years, and five years. Follow up was one to five years post-implantation. The dislocation rate was zero. The combination of a large dual-mobility femoral head, combined with a soft tissue repair that spares the deep capsule, has the potential to significantly reduce dislocation rates when using the posterior approach to the hip.
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Intra-Operative Ultrasound: Tips and Tricks for Making the Most in Neurosurgery
Roberto Altieri, MD, Neurosurgeon, Francesco Zenga, MD, Neurosurgeon, Antonio Melcarne, MD, Neurosurgeon, Giuseppe Di Perna, MD, Resident in Neurosurgery, Chiara Fronda, MD, Neurosurgeon, Fabio Cofano, MD, Resident in Neurosurgery, Alessandro Ducati, MD, Professor of Neurosurgery, Diego Garbossa, MD, PhD, Professor of Neurosurgery, University of Turin, Turin, Italy, Francesco Maria Calamo Specchia, MD, Neurosurgeon, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy, Giuseppe La Rocca, MD, Neurosurgeon, Giovanni Sabatino, MD, Neurosurgeon, Giuseppe Maria Della Pepa, MD, Neurosurgeon, Alessandro Olivi, MD, Professor of Neurosurgery, Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
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Purpose: Advances in intraoperative imaging and neuronavigation techniques have positively affected glioma surgery. The desire to reduce brain-shift-related problems while achieving the real-time identification of lesions and residual and anatomical relationships has strongly supported the introduction of intraoperative ultrasound (ioUS) in neuro-oncological surgery. This paper presents tips based on our experience with ioUS in neurosurgery.
Methods: We retrospectively analyzed 264 patients who underwent high-grade glioma (HGG) resection at the University of Turin and 60 patients who were treated at the University of Rome.
Results: The main issues are the correct choice of the probe and how to evaluate the anatomy to understand how the information from the three common US planes (axial, sagittal and coronal plane) can be used in each case. It is also important to correctly identify anatomical structures in ioUS imaging. In a normal brain, the sulci, sickle, tentorium, choroid plexus, ependyma and the walls of the vessels are all hyperechoic. In addition, some structures are hypoechoic with a homogeneous acoustic gradient: ventricles, cysts and everything that contains liquor. Tumors are usually hyperechoic in ioUS because of their higher cellularity. Conversely, acute edema that contains fluid is hypoechoic, while chronic edema is hyperechoic.
Conclusions: IoUS is a real-time, accurate and inexpensive imaging method. The difficulties of interpretation can be overcome by experience in US imaging and a better understanding of the interaction between navigation and imaging fusion techniques. Training on a large number of cases is important for the correct assessment of ioUS information to obtain valuable, real-time information during HGG surgery.
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Step-by-step Illustration of the Cranial Bifrontal Approach
Marcelo Galarza, MD, PhD, Associate Professor, Regional Service of Neurosurgery, University Hospital Vírgen de la Arrixaca, Murcia, Spain
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Based on experience with several hundreds of adult and pediatric patients in whom the cranial bifrontal approach was used to achieve different surgical objectives, this paper describes this approach in a step-by-step manner with illustrations. This is a basic approach to the anterior cranial fossa that enables the preservation of most bridging veins. The bifrontal approach, whether basal, interhemispheric, or both, allows a wider bilateral operative field with better orientation and views of important neural structures and perforating arteries, without needing to be combined with other approaches. The following description should be regarded as a basic technique to arrive at a definite location within the anterior cranial compartment and beyond, rather than as rigid steps that must be followed rigorously. These illustrations are intended to present essential principles of a standard bifrontal approach. Since the same principles can be followed for every bifrontal approach, this technique along with the surgical results can be constantly improved.
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