Quantification of level I neck lymph nodes for lymph node transfer in lymphedema treatment: an anatomical study and review of literature.

Background: Vascularized lymph node transfer (VLNT) is an effective microsurgical method for the treatment of lymphedema. Knowledge of lymph node quantity and regional anatomy of donor sites are essential for surgery optimization. The aim of the study was to quantify the level I lymph nodes of the neck (submental and submandibular lymph nodes), describe the regional anatomy and review the current literature. Methods: Level I lymph nodes were identified from pathology specimens of 73 patients in Melbourne, Australia who underwent radical, modified, and selective neck dissection were quantified. Level I was further subcategorized into levels IA (submental) and IB (submandibular), with data assessed qualitatively and quantitatively. PubMed, Google Scholar, Science Direct, Cochrane CENTRAL, and trial registries (http://clinicialtrials.gov/) were searched for relevant studies published from infinity to December 2021. Results: A mean of 5.2±2.9 lymph nodes were identified in the level I neck region. Subcategorization into level IA and level IB showed means of 3.7±1.6 and 4.7±3.0 lymph nodes, respectively. No statistical differences were detected regarding patients' gender (P=0.8) and age (P=0.5). Current literature shows level I neck VLNT is a suitable treatment for lymphedema. Conclusions: Level I of the neck offers a consistent quantity of lymph nodes and is suitable for free lymph node transfer. Current literature states VLNT is an effective technique for lymphedema treatment. This study details the regional anatomy of the level I neck lymph nodes, which will assist surgeons to optimize their surgeries and prevent donor-site morbidity.

The "Trigger" Thumb Locked in Extension - An Unusual Presentation of a Common Paediatric Condition.

BACKGROUND: We report a variant of paediatric trigger thumb which is locked in extension rather than flexion. METHODS: Eleven children with 14 trigger thumbs (three bilateral) locked in extension were reviewed retrospectively over a 12-year period. The number of flexed trigger thumbs encountered over this period was established from the operating room database. RESULTS: All children were treated with release of the A1 pulley. Nine children achieved a full range of motion at the interphalangeal joint. One child with bilateral extended trigger thumbs required bilateral dorsal capsulotomy and another child developed temporary mild triggering in flexion. CONCLUSIONS: Approximately 1% of trigger thumbs treated operatively at this institution presented as the extended variant. Trigger thumb locked in extension should be considered in a child presenting with inability to flex the thumb.

Free distal volar forearm perforator flap: clinical application in digital reconstruction.

INTRODUCTION: Soft tissue defects of the digits can be a challenging problem for the hand surgeon. For non-graftable defects, numerous local, regional and free flaps have been described for resurfacing, each with their own limitations - bulk, colour, texture mismatch, donor morbidity. Perforator flaps increasingly provide the optimal option for reconstruction of digital defects as they are thin, pliable and with low donor site morbidity. METHODS: A thin, pliable fasciocutaneous flap can be raised from the distal volar forearm based on a perforator of the radial artery. The pedicle is up to 2-3 cm in length with a diameter of at least 0.5 mm in diameter, suitable for anastomosis to the digital artery. Venous drainage is via the venae comitante of the radial artery and superficial volar veins. RESULTS: A patient presented to our emergency department following circular saw injuries. He suffered multi-digit trauma with subsequent soft tissue defects over the dorsum of the digit. Reconstructive requirements were met utilizing a free fasciocutaneous flap raised on a distal volar forearm perforator from the radial artery. The recovery was uneventful with no donor site morbidity. DISCUSSION: Dorsal digital soft tissue reconstruction requires thin, pliable, ideally hairless and sensate skin. Most locoregional options are limited by the need for multi-stage surgery, bulk, limited reach or donor site morbidity. In our patient, the reconstructive requirements were met with preservation of the radial artery. While it requires microsurgical skill and instruments, this flap provides another option for the reconstructive hand surgeon.

The vascular basis of the hemi-hamate osteochondral free flap. Part 2: surgical anatomy and clinical application.

PURPOSE: The free vascularised hemi-hamate flap combines the utility of providing a small osteochondral portion of hamate for reconstruction, while providing a means of vascularisation to preserve articular cartilage after transfer. In Part 1 of this series, we highlighted the vascular approaches to such a technique. The current study investigates the bony architecture of the hamate, with particular emphasis on its utility for a range of osteochondral defects in the hand. METHODS: A morphometric assessment of the hamate as a potential osteochondral flap donor site for resurfacing digital phalangeal heads (either total or unicondylar) and/or bases was thus undertaken. This anatomic study was undertaken using in vivo imaging performed for a range of clinical indications, with computed tomographic angiography (CTA) and digital subtraction angiography (DSA) of the upper limb included. Bony and vascular measurements and relationships were recorded and assessed both quantitatively and qualitatively. A clinical case is presented, highlighting the application of these measurements. RESULTS: The mean digital artery diameter was 0.7 mm with a mean distance between digital artery and interphalangeal joint surface (i.e. pedicle length) of 1.18 mm. Mean hamate dimensions comprised a transverse width 16.62 mm, lateral width of 14.29 mm and ridge height of 1.43 mm. Measurements of the phalangeal bases, condyles and total phalangeal heads were recorded, and the optimal hamate harvest approaches demonstrated. Despite perceived differences, in all cases there was statistical similarity demonstrated between the fragments. CONCLUSION: The hemi-hamate osteochondral flap can be applied to a range of osteochondral defects in the hand and may offer new options to the hand surgeon.

The vascular basis of the hemi-hamate osteochondral free flap. Part 1: vascular anatomy and clinical correlation.

PURPOSE: The treatment of comminuted fractures of the proximal interphalangeal joint is highly challenging due to the complexities of joint bio-mechanics and stability. The hemi-hamate osteochondral auto-graft has been popularised in this role, able to replace articular loss and restore joint stability. Recent evaluation of their long-term follow-up however has shown the early development of osteoarthritis and potential early cartilage loss, which may be due to the non-vascularised nature of the graft. We offer a new technique that maintains vascularisation of the transferred hamate fragment, and investigate the anatomical vascular basis for the technique. METHODS: Dissection and angiographic studies of ten cadaveric specimens were undertaken, exploring the vascular anatomy of the dorsal hamate. A clinical case of hemi-hamate osteochondral free flap is presented, including preoperative, intraoperative and postoperative investigation of the relevant vasculature. RESULTS: Cadaveric studies demonstrated dorsal vascular supply to the hamate from the central of three dorsal carpal arches. The arch was supplied by the dorsal branch of the ulnar artery. Multiple supracapsular veins are present for use in flap venous drainage. This vascular pattern was found to be constant. A clinical case of hemi-hamate osteochondral free flap harvest demonstrated the same vascular anatomy intraoperatively. The digital artery was used as a recipient for microvascular anastomosis. Postoperative computed tomographic angiography and nuclear bone scan confirmed flap perfusion. CONCLUSIONS: The hemi-hamate osteochondral flap has a reliable anatomical vascular basis, and is clinically feasible as a technique for early vascularisation of the osteochondral fragment to sustain the transferred articular cartilage.

Bushfire disaster burn casualty management: the Australian "Black Saturday" bushfire experience.

Mass burn disasters are among the most difficult disasters to manage, with major burns requiring complex management in a multidisciplinary setting and specialist burns services having limited capacity to deal with large numbers of complex patients. There is a paucity of literature addressing health system responses to mass burn disasters resulting from wildfires, with the events of the "Black Saturday" disaster in the state of Victoria, Australia, able to provide a unique opportunity to draw lessons and increase awareness of key management issues arising in mass burn casualty disasters. The event comprised the worst natural disaster in the state's history and one of the worst wildfire disasters in world history, claiming 173 lives and costing more than AUD 4 billion. This article draws on the national burns disaster plan instituted, Australian Mass Casualty Burn Disaster Plan (AUSBURNPLAN), and details the management of mass burn cases through a systems-based perspective.

Reconstruction of the irradiated extended abdominoperineal excision (APE) defect for locally advanced colorectal cancer.

PURPOSE: There is substantial evidence for neoadjuvant chemoradiotherapy and extended abdominoperineal excision (APE) for improving local recurrence rates and overall survival for rectal carcinoma. While oncologic outcomes are improved, the large irradiated defect in the pelvic floor can potentiate poor operative outcomes. We describe a reconstructive option, the inferior gluteal artery myocutaneous (IGAM) transposition flap, which can enable wide tumour resections by providing substantial non-irradiated tissue bulk. METHODS: Ten consecutive patients underwent either standard APE with direct primary closure or extended APE with IGAM transposition flap reconstruction between 2007 and 2009 for mStage I-IIIC disease. Patients underwent staging computed tomography and pelvic magnetic resonance imaging, and neoadjuvant chemoradiotherapy after multi-disciplinary team discussion. Eight patients underwent extended APE and IGAM transposition flap reconstruction due to locally advanced stage of their carcinoma. Oncologic, reconstructive and post-operative outcomes were assessed. RESULTS: All cases demonstrated good closure of the APE defect, with no intra-operative perforations and no immediate operative complications. Histological margins were clear (R0) in all specimens, with mean closest distance to margin 10.8 mm (range 4-20 mm). Mean follow-up was 11.3 months, with no locoregional recurrences. There was no donor site morbidity and no perineal hernia; patients reported high degrees of satisfaction with aesthetic outcome. CONCLUSION: As the extended APE becomes increasingly utilized for rectal carcinoma, a reliable reconstructive option is increasingly important. The IGAM island transposition flap imports well-vascularized, non-irradiated tissue to reconstruct the defect, provides tissue bulk and potentiates good oncologic and reconstructive outcomes.

Surgical options for reconstruction of the extensor mechanism of the knee after limb-sparing sarcoma surgery: an evidence-based review.

BACKGROUND: Limb-salvage surgery remains current best practice for management of soft tissue and bony sarcomas about the knee, with the range of reconstructive options all providing reassuring levels of long-term survival and function. There is no current consensus as to the best method of reconstruction of the extensor mechanism of the knee (quadriceps-patellar complex), with a wide variety of options proposed. The techniques described in the literature include prosthetic reconstruction, soft tissue reconstruction (comprising reconstruction with pedicled muscle flaps or autogenous tendon grafts), and bony reconstructions (including vascularised fibula flaps). An evidence-based literature review assessing the available reconstructive options has not been undertaken. METHODS: A thorough literature review was undertaken, evaluating the current evidence regarding the use of surgical techniques for reconstruction of the extensor mechanism of the knee following oncologic resection. The literature identified was critically evaluated based on the current Oxford Centre for Evidence-Based Medicine definitions. RESULTS: There are no randomised trials in the literature in this setting, and thus no level 1 or level 2A studies to support any given technique. As such, there are many favourable techniques for reconstruction that have been well described and have some evidence base to support their use. Overall, there is a trend towards improved outcomes with biological reconstructive options, with lower reported levels of failure, infection and amputation. Despite this, no single technique has adequately proven to be superior. CONCLUSION: Given the proposed difficulties in randomising patients, good evidence for the optimal reconstructive choices may be hard to establish.

Inferior gluteal artery myocutaneous island transposition flap reconstruction of irradiated perineal defects.

BACKGROUND: With the progressive use of more radical surgical resections and pre-operative chemo-radiotherapy for locally advanced anorectal cancers, there has become an increasing need for reconstructive options that import well-vascularised tissue of sufficient bulk to the perineum. We present our technique of inferior gluteal artery myocutaneous (IGAM) transposition flaps for reconstruction after extended abdomino-perineal excision (APE) for anorectal cancer. METHODS: Six consecutive male patients with T2/T3 rectal carcinoma underwent neoadjuvant chemo-radiotherapy followed by extended APE and immediate reconstruction with an islanded IGAM transposition flap. The operative technique and surgical outcomes were assessed with follow-up ranging from 3 to 18 months (median 5 months). RESULTS: In all cases, there were clear histological margins with no flap failures or partial flap losses, and no post-operative hernias. There were no major wound complications, with only one superficial breakdown associated with high body mass index (BMI) and adhesive tape allergy, treated with dressings alone. There was no donor site morbidity evident following flap harvest. CONCLUSION: The IGAM island transposition flap provides excellent tissue bulk, a large reliable skin paddle and a long pedicle that permits flexible positioning with tension free closure. Our successful results and high patient satisfaction make it a favourable option that should be considered when faced with this reconstructive challenge.

Acute chylous ascites mimicking acute appendicitis in a patient with pancreatitis.

We report a case of acute chylous peritonitis mimicking acute appendicitis in a man with acute on chronic pancreatitis. Pancreatitis, both acute and chronic, causing the development of acute chylous ascites and peritonitis has rarely been reported in the English literature. This is the fourth published case of acute chylous ascites mimicking acute appendicitis in the literature.

Incomplete excision of squamous cell carcinoma of the skin: a prospective observational study.

BACKGROUND: Squamous cell carcinoma is the second most common cancer of the skin. It behaves differently from basal cell carcinoma. Few large-scale studies have identified risk factors for incomplete excision of cutaneous squamous cell carcinoma. The authors report the largest prospective study to identify the risk factors for incomplete excision of these lesions. METHODS: A total of 517 histopathologically confirmed squamous cell carcinomas were excised from January of 2001 to December of 2002 at the Peter MacCallum Cancer Institute. Of these, 480 primary excisions were analyzed. Data pertaining to patient age, sex, lesion size, margin of excision, recurrence, previous excision, site, anesthetic choice, and repair method were collected prospectively. RESULTS: The overall incomplete excision rate was 6.3 percent. Lesions on the ear (p < 0.003), re-excisions (p < 0.001), and invasive lesions (p < 0.001) were associated with the highest incomplete resection rates. Age (p = 0.61), sex (p = 0.075), tumor size (p = 0.521), surgeon's experience (p = 0.092), and recurrent lesions (p = 0.408) were not statistically significant risk factors. CONCLUSIONS: Statistically significant risk factors were ear lesions, invasive lesions, and previously incompletely excised lesions referred for re-excision. The authors recommend more care with tumor markings, taking margins of at least 5 mm, using deeper margins, and referring patients to more experienced centers.

Incomplete excision of basal cell carcinoma: a prospective trial.

BACKGROUND: As a measure of the standard of surgical care, incomplete excision of skin malignancy is an important clinical indicator, developed by the Royal Australasian College of Surgeons and the Australian Council on Healthcare Standards. Reported rates of incomplete excision of basal cell carcinoma vary widely (5 to 25 percent) among centers worldwide. This prospective study reports on the incidence of incomplete excision at a tertiary referral public hospital and determines the factors that may influence this. METHODS: From January of 2001 to December of 2002, 1214 basal cell carcinomas were excised at Peter MacCallum Cancer Centre. Data were collected prospectively and analyzed using the FileMaker Pro program and SPSS software. RESULTS: The overall percentage of incomplete excision was 11.2 percent for primary excisions. Risk factors for incomplete excision are the head site; morpheic, superficial, and infiltrative subtypes; lesions larger than 20 mm in diameter; the presence of multiple lesions; repair by skin graft; and recurrent and previously incompletely excised basal cell carcinomas. The type of anesthetic used did not affect outcome. There was no significant difference in the percentage of incomplete excision between consultants, registrars, and the clinical assistant, but this was probably attributable to the small number of cases performed by consultants at Peter MacCallum Cancer Centre. CONCLUSIONS: This is the largest prospective study of incomplete excision of basal cell carcinomas. The authors' result is within the range reported in the current literature but is higher than anticipated. Preoperative "red-flagging" of basal cell carcinomas most at risk of incomplete excision may lead to a better result.

Undergraduate experience of surgical teaching and its influence and its influence on career choice.

BACKGROUND: The purpose of this survey was to determine the views of final year medical students in Melbourne regarding both undergraduate surgical teaching and the students' career aspirations. METHODS: A structured questionnaire was given to all final year medical students at Monash and Melbourne Universities in 2003. The questions dealt with the factors influencing graduating medical students, including theatre experience, encouragement/support from surgeons, presence of mentors, lifestyle factors and gender issues. RESULTS: The response rate was 61.2% (251/410). Of these, 50.6% were male, 32.3% declared an interest in surgical training with the remainder either uncertain (24%) or uninterested (44%). Male students were more likely to be interested in surgery. General surgery was the most popular field (69%), followed by plastic surgery (37%) and orthopaedic surgery (35%). Of respondents, 78% reported positive influences towards pursuing a surgical career during their undergraduate years, while 63% reported a negative experience. A total of 67% believed that the current curriculum is adequate and 43% that there is enough support/encouragement towards a surgical career. Only 44% of respondents reported that surgeons are approachable. Lifestyle and family factors were the most important career influence. In particular, 57% of female respondents felt discouraged from pursuing a surgical career and 99% of these women reported lifestyle/family factors as the main source of discouragement, with a further 72% identifying a lack of female role models. CONCLUSIONS: This survey highlights important issues in current undergraduate perception of surgical teaching and higher training. Issues that may encourage or discourage a graduating student to pursue a surgical career are identified.

Clinical diagnosis of skin tumours: how good are we?

BACKGROUND: Few studies have addressed the accuracy of clinical diagnosis of skin malignancies. The present prospective study aims to determine the accuracy with which these lesions are diagnosed and attempts to identify the factors influencing the accuracy of clinical diagnosis. METHODS: All patients undergoing surgical excision of a skin cancer with curative intent from January 2001 to December 2002 at Peter MacCallum Cancer Institute, Melbourne, Australia were prospectively studied. Data were entered into the Filemaker Pro program and analysed using the SPSS software package. RESULTS: A total of 2582 lesions were surgically excised from 1223 patients. Of these 47% were basal cell carcinomas (BCC), 20% were squamous cell carcinomas (SCC), 0.9% were malignant melanomas (MM), and 32.1% were benign or premalignant. Tumours, benign and malignant, were found to be more common in men. The sensitivity for clinical diagnosis of malignancy was 97.5% while the positive predictive value (PPV) for clinical diagnosis of malignancy was 70.3%. BCC and SCC was diagnosed with a sensitivity of 89% and 56.3%, and PPV of 64.5% and 40.3%, respectively (P < 0.001). 23 MM were excised with a sensitivity of clinical diagnosis of 47.8% and PPV of 30.6%. Sensitivity and PPV were also assessed according to clinical experience of the surgeon, site of the lesion and whether surgery was performed for a primary or a recurrent lesion. Sensitivity and PPV were higher for lesions diagnosed by consultant surgeons when compared with surgical trainees (P < 0.001) - MM was diagnosed with a sensitivity of 100% by consultant surgeons. CONCLUSION: The present study shows sensitivity and PPV rates comparable to published figures.