Preoperative Prophylactic Antibiotics in Mandibular Fractures and Surgical Site Infection.

BACKGROUND: Compared with other facial fractures, mandibular fractures have the highest rate of postsurgical site infection. There is strong evidence to suggest that postoperative antibiotics do not reduce rates of surgical site infections (SSIs) regardless of duration. However, there are conflicting data in the literature regarding the role of prophylactic preoperative antibiotics in reducing rates of SSIs. This study reviews the rate of infections in patients who underwent mandibular fracture repair who received a course of preoperative prophylactic antibiotics compared with those who received no or 1 dose of perioperative antibiotics. METHODS: Adult patients who underwent mandibular fracture repair at Prisma Health Richland between 2014 and 2019 were included in the study. A retrospective cohort review was conducted to determine the rate of SSI, comparing 2 groups of patients who underwent mandibular fracture repair. Patients who received more than 1 dose of scheduled antibiotics before surgery were compared with those who did not receive any antibiotic treatment before surgery or received only a single dose of antibiotics within 1 hour of incision time (perioperative antibiotics). The primary outcome was the rate of SSI between the 2 groups of patients. RESULTS: There were 183 patients who received more than 1 dose of scheduled antibiotics before surgery and 35 patients who received a single dose of perioperative antibiotics or did not receive any antibiotics. The rate of SSI was not significantly different in the preoperative prophylactic antibiotics group (29.3%) compared with the patients who received a single perioperative dose or no antibiotics (25.0%). CONCLUSION: Extended regimens of preoperative prophylactic antibiotics beyond a single dose at time of surgery do not reduce SSIs after surgical repair in mandibular fractures.

The Utility of the 5-Factor Modified Frailty Index to Predict Postoperative Risk in Microsurgical Reconstruction.

BACKGROUND: Microsurgical reconstruction is an integral part of plastic surgery. The 5-factor modified frailty index (5-mFI) is an effective tool to predict postoperative complications across multiple subspecialties. We aimed to determine if frailty scores using the 5-mFI can predict postoperative complications specifically in microvascular reconstruction. STUDY DESIGN: Frailty scores were retrospectively assessed in microsurgical reconstruction patients (2012-2016) using the American College of Surgeons National Quality Improvement Program base. The 5 variables that comprise the 5-mFI are history of chronic obstructive pulmonary disease, history of congestive heart failure, functional status, hypertension requiring medication and diabetes. The data were analyzed using the Goodman test, χ2 test, and a logistic regression model. The congruence was also compared between the 5-mFI and the American Society of Anesthesiology (ASA) classification in predicting complications. RESULTS: Of 5894 patients, the highest 5-mFI value was "3." Analyses show an increase in postoperative complications requiring ICU care. Further models indicate an association between readmission with hypertension and chronic obstructive pulmonary disease (P < 0.05). There was an increased risk of a failure to wean from ventilator with a history of chronic obstructive pulmonary disease and diabetes and an increased risk of readmission with a history of hypertension and chronic obstructive pulmonary disease. The 5-mFI and ASA were incongruent in predicting postoperative complications. CONCLUSIONS: The 5-mFI predicts postoperative complications in the microsurgical reconstruction population. Although the 5-mFI and ASA predict different complications, their use provides insight into the potential adjustable risks before surgery.

Palmar Creases and Their Implication on Carpal Tunnel Surgery.

BACKGROUND: A thorough knowledge of normal and variant anatomy of the wrist and hand is fundamental to avoiding complications during carpal tunnel release. The purpose of this study was to document variations of the surface anatomy of the hand to identify a safe zone in which the initial carpal tunnel incision could be placed. The safe zone was identified as the distance between the radial side of hook of hamate and the ulnar edge of the origin of the motor branch of the median nerve (MBMN). METHODS: Kaplan's cardinal line and other superficial markers were used to estimate the size of the safe zone, in accordance to prior published anatomical studies. The presence of a longitudinal palmar crease (thenar, median, or ulnar creases) within the safe zone was recorded. RESULTS: Of the 150 participants (75 male, 75 female) examined, the average safe zone widths were 10.85 (right) and 10.28 (left) mm. In all the hands examined, 86.33% of the safe zones (259 of 300) contained a longitudinal palmar crease. In the White population (n = 50), the average safe zone widths were 11.49 (right) and 10.01 (left) mm; in the African American population (n = 50), the average safe zone widths were 12.27 (right) and 12.01 (left) mm; and in the Asian population (n = 50), the average safe zone widths were 8.79 (right) and 8.82 (left) mm. On overage, males had a larger safe zone width than females by 4.55 mm. CONCLUSIONS: Although there seems to be variability between race and sex with regard to safe zone width, finding 86.33% of longitudinal palmar creases within the safe zone suggests that, for most patients, the initial carpal tunnel surgery incision may be hidden within the palmar crease while minimizing the risk of motor branch of the median nerve injury. Overall, the safe zone width is on average up to 10.5 mm measured from the hook of the hamate along Kaplan's cardinal line.

The Role of Maximal Locoregional Block in Autologous Breast Reconstruction.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) has become the standard of care in microsurgical breast reconstruction. The current literature provides overwhelming evidence of the benefit of ERAS pathways in improving quality of recovery, decreasing length of hospital stay, and minimizing the amount of postoperative narcotic use in these patients. However, there are limited data on the role of using maximal locoregional anesthetic blocks targeting both the abdomen and chest as an integral part of an ERAS protocol in abdominally based autologous breast reconstruction. The aim of this study is to compare the outcomes of implementing a comprehensive ERAS protocol with and without maximal locoregional nerve blocks to determine any added benefit of these blocks to the standard ERAS pathway. METHODS: Forty consecutive patients who underwent abdominally based autologous breast reconstruction in the period between July 2017 and February 2020 were included in this retrospective institutional review board-approved study. The goal was to compare patients who received combined abdominal and thoracic wall locoregional blocks as part of their ERAS pathway (study group) with those who had only transversus abdominis plane blocks. The primary end points were total hospital length of stay, overall opioids consumption, and overall postoperative complications. RESULTS: The use of supplemental thoracic wall block resulted in a shorter hospital length of stay in the study group of 3.2 days compared with 4.2 days for the control group (P < 0.01). Postoperative total morphine equivalent consumption was lower at 38 mg in the study group compared with 51 mg in the control group (P < 0.01). Complications occurred in 6 cases (15%) in the control group versus one minor complication in the thoracic block group. There was no difference between the 2 groups in demographics, comorbidities, and type of reconstruction. CONCLUSION: The maximal locoregional nerve block including a complete chest wall block confers added benefits to the standard ERAS protocol in microvascular breast reconstruction.

Modified Carpal Tunnel Release: A New Approach to Minimizing Pillar Pain.

INTRODUCTION: Pillar pain is a frequent postoperative complication of carpal tunnel release (CTR). The precise definition of pillar pain is lacking, but most authors describe it as diffuse aching pain and tenderness in the thenar and hypothenar area. The etiology of pillar pain is unclear. However, the most prevalent theory is the neurogenic theory, which attributes the pain to the damage of small nerve branches of palmar cutaneous branches of median nerve after surgical incision, with resulting entrapment of the nerves in the scar tissue at the incision site. We postulated that a main source of pillar pain is sensory neuromas along the incision site.In this article, we describe a simple modification of the standard CTR technique with intent to decrease neuroma formation and thus minimizing pillar pain. MATERIALS AND METHODS: This is a retrospective study comparing the incidence and duration of pillar pain between patients who underwent standard CTR (SCTR, n = 53) versus the minimizing pillar pain CTR technique (n = 55). Based on duration of pillar pain, the groups were placed into 3 subgroups (<3, 3-6, and >6 months). Presence and duration of pillar pain in each group were recorded along with return to work (RTW), complications, and patient satisfaction. RESULTS: The SCTR group had a total of 17 patients with pillar pain (32.1%), 5 of which resolved within 3 months, 7 within 3 to 6 months, and 5 in more than 6 months. The group that underwent the minimizing pillar pain technique had a total of 4 patients with pillar pain (7.2%). Three resolved within 3 months, 1 resolved within 3 to 6 months, and there were no patients with pillar pain lasting more than 6 months. Average RTW time for minimization of pillar pain CTR (MPPCTR) was 34.9 days. Average RTW time for SCTR was 54.8 days. Satisfaction was higher among patients who underwent surgery with MPPCTR. CONCLUSIONS: Based on these results, we concluded that MPPCTR compared with SCTR had equal complication rate, however, significantly lower incidence and duration of pillar pain, higher rate of satisfaction, and earlier RTW.

Sternotomy Wound Closure: Equivalent Results with Less Surgery.

BACKGROUND: Mediastinitis after a median sternotomy can be life-threatening. The advent of pedicle flap-based treatment has resulted in an improvement in both morbidity and mortality. However, significant morbidities can still occur following the use of flaps for sternal closure, particularly in patients with comorbidities. To minimize an extensive surgical dissection, we modified our approach to reconstruction using a modified subpectoral approach, leaving the overlying skin attached. This technique focuses primarily on controlling wound tension rather than on maximal muscle coverage. This study is a retrospective review of 58 consecutive patients treated with this approach, by a single surgeon. METHODS: Fifty-eight consecutive patients treated between 2008 and 2019 were included. All patients received the same procedure regardless of the degree of illness, the extent of tissue loss, and the size of sternal defect. Treatment included thorough debridement, with total sternectomy (if required); limited dissection of the pectoralis major muscle off the chest wall to the level of the pectoralis minor without skin and subcutaneous undermining; no release of the insertion of the pectoralis or use of the rectus abdominis; and midline closure over drains connected to wall suction to obliterate dead space. RESULTS: Reoperations were required in 7 patients (12%). Of these, only 4 (6.9%) were related to continued sternal osteomyelitis. The other reoperations were for hematoma evacuation, breast fat necrosis, and skin necrosis. There were no operative mortalities. CONCLUSION: Chest closure using minimal dissection and tension release is safe, efficient, and associated with a complication rate equivalent to more extensive procedures reported in the literature despite significant comorbidities.

Laparoscopic Roux-en-Y gastric bypass in a patient with situs inversus totalis: Case report, technical tips and review of the literature.

INTRODUCTION: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has proven over the years to be one of the most effective bariatric procedures. It is highly technical, and therefore is mostly performed by bariatric and metabolic surgeons. Although Situs Inversus Totalis (SIT) is a very rare congenital condition, surgeons do occasionally have to operate intra-abdominally on those patients, consequently facing some challenges related to the unusual anatomy. CASE PRESENTATION: We describe a rare case of LRYGB for chronic morbid obesity on a 43 year old patient with pre-operative diagnosis of situs inversus totalis without Kartagener's syndrome, using slight modification from the usual technique based on anatomical correlation without the need to change the surgeon's position or switching trocar placements as described in previous papers. This could help surgeons in general reduce the potential challenges faced when performing such procedure. CONCLUSION: Situs Inversus Totalis is a rare congenital condition, but surgeons in general do encounter those patients throughout their career. This rare condition should not solely be an indication for an open approach as minimally invasive surgery, whether laparoscopic or robotic, is safe and should still be considered the standard of care approach. Bariatric surgery is one of the most technical intra-abdominal procedures mainly due to the patients' body habitus, different instrumentations used, and the different anastomoses created. Gastric bypass and bariatric surgery in general can be safely performed on patients with SIT without the need for major adjustment to the surgeon's position, trocar placement or instruments used.

Non-traumatic perforation of common hepatic duct: Case report and review of literature HP.

INTRODUCTION: Non-traumatic biliary perforation other than the gallbladder is extremely rare and most commonly seen in children in association with congenital biliary anomalies. We present a rare case of choledocholithiasis that progressed to spontaneous perforation of the common hepatic duct probably from ischemic necrosis caused by impaction of large biliary stones. CASEREPORT: A 62-year-old female presented with diarrhea and jaundice. She was found to have two 2.5cm stones in the common hepatic duct. Stones could not be extracted by ERCP, and placement of biliary stent was done to restore patency. The patient was lost to follow up and returned after three months with a new onset of similar symptoms. At that time ERCP and a stent change were done without resolution of the symptoms. Patient then underwent an open exploration and was found to have a free perforation in the lateral aspect of the common hepatic duct just at the bifurcation of the right and left hepatic radicals. Through this perforation stones were both extracted and cholangiogram showed free flow with the distal biliary stent. The stent was nowhere near the site of perforation which appeared to be caused by pressure necrosis from the impacted stones. CONCLUSION: Impacted stones in the biliary tree need to be extracted to avoid pressure necrosis and spontaneous perforation. ERCP and stent placement should be used only as temporizing measures to manage the acute obstructive phase. Definitive surgical intervention must follow initial biliary decompression to extract the impacted biliary stones and avoid complications.

Herniation through gastrostomy site: Case report.

INTRODUCTION: Herniation through gastrostomy site is an extremely rare complication of percutaneous endoscopic gastrostomy (PEG). We present two unusual cases of gastrostomy site herniation, the surgical management thereof, and a corresponding review of the literature. CASE PRESENTATION: The first patient is a 65year old Caucasian male who complained of epigastric pain and a bulge at his previous gastrostomy tube incision site three weeks after its removal. Initial exam revealed a hernia measuring approximately 10cm which was later repaired by laparoscopic surgery with a composite mesh. The second case is 66year old obese Caucasian male who complained of continued pain in the midepigastric region around his gastrostomy site scar five months after removal of his PEG tube. On physical exam he was found to have a hernia of 6cm in the midepigastrium. His hernia was later repaired by open surgery with a composite mesh. Both patients recovered uneventfully postoperatively. CONCLUSION: Herniation through gastrostomy site is a possible complication of PEG tube and clinicians should consider this possibility in patients with ongoing leakage, bulge or pain at the gastrostomy site. This entity can be safely corrected via laparoscopic or open techniques.