Salvage of vascular graft infections via vacuum sealing drainage and rectus femoris muscle flap transposition: A case report

BACKGROUND The management of vascular graft infections continues to be a significant challenge in a clinical situation.The aim of this report is to illustrate the novel vacuum sealing drainage(VSD)technique and rectus femoris muscle flap transposition for vascular graft infections,and to evaluate the prospective of future testing of this surgical procedure.CASE SUMMARY We report the case of a 32-year-old male patient,who presented a severe infected groin wound with biological vascular graft Acinetobacter baumannii infection resulting in extensive graft exposure.Using the VSD and muscle flap transposition,the groin wound and vascular graft infection were finally treated successfully.CONCLUSION Our case report highlights that VSD technique and rectus femoris muscle flap transposition could be considered in patients presenting with a severe infected groin wound with biological vascular graft Acinetobacter baumannii infection resulting in extensive graft exposure,especially in consideration of treatable conditions.

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

Objective: The aim of this study was to improve muscle flaps and to evaluate surgical outcomes with the use of a novel specialized retractor, which is a surgical instrument used to locate and shape a bony seat for minimally invasive cochlear implantation.Methods: 50 patients aged 1 e75 years with sensorineural hearing loss who required cochlear implantation were recruited. A small incision(<3 cm) was made, and the novel specialized retractor was used in the study group during cochlear implantation. The incision length, surgical outcomes and operative time were recorded and analyzed.Results: The incision length, total operative time and drilling bony time were shorter in the study group than in the control group(P < 0.05, respectively). All patients recovered well after the surgery without any severe complications.Conclusion: The use of a novel specialized retractor standardized the surgical processes of cochlear implantation. The retractor helped locate and control the size of the bony well during bone drilling. The tool reduced the technical difficulty and improved the efficacy of this minimally invasive operation.

Evaluation of speech function on repairing defects of maxilla and palate with temporalis muscle flap

Objective： To evaluate the speech function on repairing defects of maxilla and palate with temporalis muscle flap after benign or malignant turmor resection. Methods： The lateral cephalogram and speech intelligibility were detected in 19 cases with the operations of repairing defects of maxilla and palate by temporalis muscle flap, and their recovery of the speech function were analyzed. Results： Among the 19 patients, there were 15 cases （78.00%） with complete velopharynx, 3 cases （15.80%） with mafiginal velopharynx, and 1 case （5.26%） with insufficient velopharynx. The average speech intelligibility was 94.3%, close to the normal speech intelligibility. Conclusion： The operation of repairing defects of maxilla and palate with temporalis muscle flap can reconstruct the phonatory structure, preserve the palate function and restore the speech function after operation.

Applied distally based peroneus brevis muscle flaps for coverage of the soft tissue defects over the lower one-third of the leg, ankle and foot

Objective To investigate a simple, valuable new method for coverage of the soft tissue defect over the lower one-third of the leg, ankle and the foot. Methods The distally based peroneus brevis muscle fkps were applied for coverage of the soft tissue defects over the lower one-third of the leg,the ankle and the foot. The muscle flaps were covered with split-thickness skin grafts. Results The distally based peroneus brevis muscle flaps were applied for coverage of the soft tissue defects over the lower one-third of the leg, the ankle and the foot in 16 cases. The larges area of the soft tissue defect was 5 cm × 7 cm. The smallest was 3 cm × 4 cm. Primary healing occured in 14 cases undergoing muscle flap construction, second-stage healing occured in 2 cases, no total flap necrosis occured in any cases. Conclusion ThisChina Medical Abstracts(Surgery) technigue is a simple and complication are lesser. The successful rates are higher. This muscle flap is suitable to the mudium or small soft tissue

Harnessing the synergy of perfusable muscle flap matrix and adipose-derived stem cells for prevascularization and macrophage polarization to reconstruct volumetric muscle loss

Muscle flaps must have a strong vascular network to support a large tissue volume and ensure successful engraftment.We developed porcine stomach musculofascial flap matrix(PDSF)comprising extracellular matrix(ECM)and intact vasculature.PDSF had a dominant vascular pedicle,microcirculatory vessels,a nerve network,well-retained 3-dimensional(3D)nanofibrous ECM structures,and no allo-or xenoantigenicity.In-depth proteomic analysis demonstrated that PDSF was composed of core matrisome proteins(e.g.,collagens,glycoproteins,proteoglycans,and ECM regulators)that,as shown by Gene Ontology term enrichment analysis,are functionally related to musculofascial biological processes.Moreover,PDSF􀀀human adipose-derived stem cell(hASC)synergy not only induced monocytes towards IL-10􀀀producing M2 macrophage polarization through the enhancement of hASCs’paracrine effect but also promoted the proliferation and interconnection of both human skeletal muscle myoblasts(HSMMs)and human umbilical vein endothelial cells(HUVECs)in static triculture conditions.Furthermore,PDSF was successfully prevascularized through a dynamic perfusion coculture of hASCs and HUVECs,which integrated with PDSF and induced the maturation of vascular networks in vitro.In a xenotransplantation model,PDSF demonstrated myoconductive and immunomodulatory properties associated with the predominance of M2 macrophages and regulatory T cells.In a volumetric muscle loss(VML)model,prevascularized PDSF augmented neovascularization and constructive remodeling,which was characterized by the predominant infiltration of M2 macrophages and significant musculofascial tissue formation.These results indicate that hASCs’integration with PDSF enhances the cells’dual function in immunomodulation and angiogenesis.Owing in part to this PDSF-hASC synergy,our platform shows promise for vascularized muscle flap engineering for VML reconstruction.

The abductor hallucis muscle flap-a viable surgical solution for treating first ray soft tissue defects

Long-standing wounds are at high risk for infection.Therefore,it is critical to achieve wound healing in a timely manner;however,some complex wounds remain recalcitrant and difficult to treat.Local muscle flaps are an underutilized technique with great utility in the reconstruction of complex foot wounds.Providing a healthy bleeding base that promotes wound healing,these muscle flaps can greatly benefit the patient and prevent amputation.In this present report,we demonstrate the use of the abductor hallucis muscle flap in the reconstruction of a complex wound following bunion surgery.

Curative effect analysis of spiral pedunculated bladder muscle flap in repairing long segment ureteral defects

In the past, the surgeons usually adopted ileal ureter plasty or ureter bladder flap plasty （Boari flap plasty） to restorelong-term ureteral mucosal avulsions and long or entire ureteral segment defects caused mostly by ureteroscope operations. But there are still certain difficulties in the restoration of long segment ureteral defects （〉20 cm） using traditional methods. In order to overcome traditional surgical approaches, we designed a new ureteroplasty operation using spiral pedunculated bladder muscle flap to restore long segment ureteral defects. METHODS Six patients who presented long segment ureteral defects caused in the course of ureteroscopic lithotripsy due to ureteropelvic junction stenosis and stones （length of defects： 21-25 cm, mean length： 22.5 cm）, were given general anesthesia, and made to lay in the horizontal position while indwelling triple lumen catheters. These patients had Gibson incision in the hypogastrium of the injured sides, and we could prolong the surgical incision up to the epigastrium or the flank abdomen moderately if necessary. We exposed the retroperitoneal space, transected the umbilical ligaments, peritoneal adhesions, spermaducts or the round ligaments to dissociate the bladder to the maximum extent possible. We could increase the mobility of the bladder by dissociating the contralateral superior vesical arteries along the anterior trunk of the internal iliac artery. We could also identify the stump of the distal ureter along the path between the ureter and bladder below the iliac vessels, and then we had to ligate or transfix the ureteral stump. We dissociated the ureteropelvic junction carefully, trimmed the stump to the inclined plane in order to facilitate the anastomose between the bladder muscle flap and the trimmed ureteral stump while locating and tracting it by the suture. Filling the bladder with 400 ml of normal saline solution along the catheter, we located the anterior wall of the bladder with the suture. Before designing the spiral pedunculated bladder muscle flap, we had to identify the superior vesical arteries and their branches of the injured sides along the anterior trunk of the internal iliac artery. Then, we trimmed the shape S bladder muscle flap along the arteries＇ track while stretching the bladder by pulling the suture. The basal width of the designed flap had to be more than or equal to 2 cm, and the length should be equivalent to the injured ureter. We thenhad to wind the bladder muscle flap spirally upon the 12F catheter, followed by continuous stitching of the winding flap and interrupted embedded stitching of the serosal layer with 5-0 bioabsorbable sutures. If only we could keep the natural spiral conditions of the bladder muscle flap between the beginning of the forming ureter and the bladder, we would get a spontaneous anti-reflux structure just like the valve more than trim the base of flap to be traditional submucosal tunnel technique deliberately. We replaced the catheter with a 7F double J tube, and had to further anastomose the forming ureter to the ureteropelvic junction with bioabsorbable sutures while fixing the ureter upon the aponeurosis of the greater psoas muscle. After indwelling the three-cavity catheter and the retropubic drainage tube, we stitched the bladder incision with bioabsorbable sutures. Finally, we sutured the abdominal incision conventionally （Figure 1A and 1B）. RESULTS All six patients＇ operations were carried out smoothly and successfully. The duration of the six surgeries ranged from 60 to 120 minutes, with the average operation time being 90 minutes. During the operations, none of the patients accepted blood transfusion, and all of them recovered well after the operation. Among the six patients, the retropubic drainage tubes in four patients were removed successfully postoperation in 3 days, while the other two had theirs removed in 10 days because of mild leakage of urine. All six patients＇ surgical incisions healed well in the first attempt, and their indicators of serum creatinine and blood urea nitrogen were also normal after 2 weeks. The double J tubes were all successfully removed by a cystoscope in 3 months or so postoperation. Two patients were confirmed to have had mild uronephrosis and ureterectasia on the surgical side in the follow-up examination after 3 months, but their total renal functions were normal. 2-4 years postoperatively, the other four patients showed no obvious abnormalities in their follow-up examinations. Also,

Limited thoracoplasty and free musculocutaneous flap transposition for postpneumonectomy empyema: A case report

BACKGROUND Empyema is a severe complication following pneumonectomy that is associated with high morbidity and mortality rates.Although there are a wide variety of treatment options,successful management remains challenging when this condition is combined with a large cavity in very thin patients who had previously undergone a posterolateral thoracotomy.CASE SUMMARY We reported the case of a thin,63-year-old man with a progressive pulmonary cyst who underwent left pneumonectomy via posterolateral thoracotomy 23 years ago.After an initially uneventful postoperative course,he was readmitted with empyema and a large cavity 21 years after surgery.He was successfully treated with limited thoracoplasty,followed by free vastus lateralis musculocutaneous flap transposition.CONCLUSION This case highlights that the treatment mode of limited thoracoplasty and free vastus lateralis musculocutaneous flap transposition is safe and effective for the management of postpneumonectomy empyema with a large cavity in thin patients who had previously undergone a posterolateral thoracotomy.

Intrathoracic latissimus dorsi muscle transposition: a reliable technique for prevention of bronchopleural fistula developing after extrapleural pneumonectomy and external beam radiotherapy in malignant pleural mesothelioma

Objective: Bronchopleural fistula (BPF) is a life threatening complication after pneumonectomy. Extra thoracic skeletal muscle transposition especially latissimus dorsi muscle flap (LDMF) had been used to prevent this complication. The aim of this study was to assess the effectiveness of LDMF in preventing BPF developing after extrapleural pneumonectomy (EPP) and external radiation therapy in malignant pleural mesothelioma (MPM). Methods: Between May 1999 and Dec. 2008, 37 patients with MPM were operated upon by EPP using LDMF prophylactically to reinforce the bronchial stump, and then received external radiation therapy with or without postoperative chemotherapy. Results: The mean age of all patients was 46.7 (range 26-57) years. Twenty five patients were males and 12 patients were females. Twenty three patients had MPM of the right side and 14 patients had MPM of the left side. The peri-operative mortality was 2.7% and only few flap related postoperative morbidity were reported in the form of minor seroma and subcutaneous surgical emphysema. The median follow up was 17 (range 9-43) months. All cases completed their postoperative external radiation therapy with no reported cases of early or late BPF. Conclusion: Intrathoracic pedicled LDMF transposition is proved to be effective in prevention of BPF developing after EPP and external radiation therapy in MPM and it is advised to be a routine step in EPP in these cases and to use more sophisticated technique of postoperative external beam radiotherapy (3D conformal or IMRT) to minimize this complication.

Diaphragmatic Flap: Technique of Preparation and Indications for Use

Background: The use of a vascularized pedicle flap of diaphragmatic muscle (DF) for reconstructive procedures in the chest has many advantages. Yet, despite the excellent reported results, the use of DF has not been widespread. Some factors for the less widespread use of DF have been, concern about diaphragmatic function, hesitation to use such a vital muscle for reconstructive purposes, and most importantly, the technical aspects for the preparation of the flap. Methods: Using a cadaveric model, the vascular anatomy of the diaphragm and the steps for the preparation of the DF was defined and illustrated for both the right and left hemidiaphragm. Results: No perioperative mortality with the use of DF has been recorded. Function of the native diaphragm has not been impaired. Bronchopleural fistulas and pericardial defects have healed in all instances. Excellent repair has been achieved in all patients with esophageal lesions. The disruption of the repaired native diaphragm and visceral herniation has been reported but it has been attributed to the learning curve and the technique of repair. Conclusion: With a better understanding of the vascular anatomy of the diaphragm and a formal methodical approach to harvesting the DF, more surgeons will be encouraged to use DF with excellent results.

Multifactor analysis of the technique in total laparoscopic gastric cancer

BACKGROUND Esophageal gastric anastomosis is a common surgical technique used to treat patients with gastric cancer who undergo total gastrectomy.However,using simple anastomosis techniques alone may not meet the needs of patients in some cases and can lead to complications such as anastomotic stenosis and ulceration.In order to overcome these issues and improve patient prognosis,muscle flap reconstruction technique has emerged.Muscle flap reconstruction is a method of improving gastric-esophageal anastomosis by transplanting muscle tissue.By covering the anastomotic site with muscle tissue,it not only enhances the stability of the anastomosis site but also increases blood supply,promoting healing and recovery of the anastomosis.Therefore,the use of muscle flap reconstruction technique in esophageal gastric anastomosis during total gastrectomy for gastric cancer is increasingly widely applied.AIM To determine the effectiveness of esophagogastric anastomosis using the muscle flap reconstruction technology in total abdominal gastrectomy for gastric cancer and perform follow-up experiments to understand the factors affecting patients’prognosis.METHODS The study subjects were 60 patients with gastric cancer who were admitted to our hospital between October 2018 and January 2022.All patients underwent esopha-gogastric anastomosis using the double muscle flap reconstruction technology in total abdominal gastrectomy.Perioperative indicators were determined,and INTRODUCTION Gastric cancer is one of the most common tumors of the digestive system worldwide.Although gastric cancer may not have significant manifestations in the early stage,as the disease progresses,systemic symptoms such as emaciation,anemia,and gastric perforation are observed[1].Surgery is the main treatment strategy for gastric cancer.With recent advances in total laparoscopy,total laparoscopic radical resection has gradually become an important treatment strategy for gastric cancer.Conventional laparoscopic surgery may require at least 5-6 incisions,whereas total laparoscopic surgery requires only 3-4 small incisions,decreasing surgical trauma and postoperative pain[2].Furthermore,because total laparoscopic surgery is less invasive than conventional laparoscopic surgery,patients can generally return to normal living and working conditions more quickly[3].Moreover,total laparoscopic surgery does not leave obvious surgical scars;therefore,it is advantageous for patients who pay attention to appearance[4].Esophagogastrostomy is a method used to repair gastrointestinal anastomosis,called the“double muscle valve”.This technique requires folding the fundus of the stomach,followed by sealing it with two layers of tissue,forming a structure similar to a valve.The application of esophagogastrostomy to total laparoscopic radical resection for gastric cancer can effectively decrease the incidence of complications such as anastomotic incontinence and bile reflux and improve the surgical cure rate and postoperative quality of life,which is a recent topic of interest for surgeons.At present,systematic multivariate analyses of the application effects of esophagogastrostomy in total laparoscopic surgery for gastric cancer and their effects on prognosis remain scarce[5].In the present study,we conducted surgery and postoperative follow-up of patients with gastric cancer and collected relevant clinical data for esophagogastric anastomosis during postoperative resection for gastric cancer to ACKNOWLEDGEMENTS I would like to express my sincere thanks to all those who participated in the manuscript.

The inflammation influence on corneal surface after frontalis suspension surgery

AIM： To study the influence of frontalis muscle flap suspension on ocular surface by analyzing the clinical features and inflammatory cytokines.METHODS： A prospective, observational case series. Thirty-one eyes of 25 patients with severe congenital blepharoptosis who underwent frontalis muscle flap suspension surgery with at least 6 mo of follow-up were included in the study. The main outcome measures were margin reflex distance 1（MRD_1）, degree of lagophthalmos, ocular surface disease index（OSDI）, fluorescein staining（Fl）, tear break-up time（BUT）, Schirmer I test, and inflammatory cytokine assay.RESULTS： The degrees of lagophthalmos significantly increased after surgery. The OSDI scores significantly increased 1wk postoperatively and then decreased 4wk after operation. The Fl scores reflected corneal epithelial defects in sixteen patients at early stage postoperatively. The BUT and Schirmer I test values remained stable and did not show change compared to those before surgery. The inflammatory cytokines in conjunctival epithelial cells（including IL-1β, IL-6, IL-8, TNF-α, and IL-17A） significantly increased 1wk after the surgery（P〈0.001）, then returned to the normal level at 24wk postoperatively. The levels of inflammatory cytokine IL-1β, IL-6, IL-8, TNF-α, and IL-17A elevated significantly and were positively correlated with OSDI and Fl scores.CONCLUSION： Frontalis muscle flap suspension surgery results in lagophthalmos in early period of post-operation and relieved after months. The elevation of inflammatory cytokines level may participate in the occurrence of corneal epithelial defects at the early postoperative stage.

Management of sternal osteomyelitis and mediastinal infection following median sternotomy

Background Median sternotomy is considered the most usually performed procedure in cardiac operations. This study aimed to assess clinical effectiveness of bilateral pectoralis major muscle flaps （BPMMF） for management of sternal osteomyelitis and mediastinal infection following median sternotomy.Methods Clinical data were collected and retrospectively analyzed from twelve patients who underwent the BPMMF transposition for management of sternal osteomyelitis and mediastinal infection following median sternotomy from January 2006 to June 2009. Procedure consisted of rigorous debridement of necrotic tissues, dead space obliteration using the BPMMF, and placement of drainage tubes connected to a negative pressures generator for adequate drainage.Results No patients died of drainage, and all 12 patients had viable BPMMF when discharged from hospital. At 1 week post discharge, 2 patients presented with sternal infection but recovered following local debridement and medication. No patients showed infection recurrence during the follow-up period over 10 months.Conclusions Sternal osteomyelitis and mediastinal infection following median sternotomy may be effectively managed through rigorous debridement of infected soft tissues, resection of the damaged stermal segment, transposition of the BPMMF to fill the damaged sternum resulting from debridement, and adequate postoperative drainage.

Urethroplasty in a post irradiation urethral stricture-a review

Radiotherapy-induced urethral strictures(RIUS)decrease quality of life and present a great challenge for surgical reconstruction,especially due to proximal location,compromised vascular supply,and poor wound healing.It is unclear whether urethroplasty is an option in cases with stricture resulting from exposure to pelvic radiation.We review the pathophysiology,diagnostic workup,and disease-specific aspects of RIUS.Furthermore,we discuss several management alternatives such as excision and primary anastomosis,as well as techniques for open reconstruction with flaps.The most extensive techniques in the treatment of strictures include,for example,those using gracilis muscle flaps,as they can involve periurethral tissue to provide sufficient vascularity for excellent post-surgery urethral healing.In brief,RIUS represent a significant challenge.In carefully chosen patients,urethroplasty should be considered as a feasible and durable treatment.However,medical practitioners should always take into consideration that the results of urethroplasty in RIUS are not comparable to urethroplasties without a radiation background.

Penoscrotal defect:a functional,esthetic,and psychological challenge

Aim:Penoscrotal defects may be caused by a variety of events.Reconstruction of the penoscrotal region is required not only for aesthetic appearance but also for functional and psychological reasons.Numerous techniques have been described for penoscrotal reconstruction reflecting the challenge and complexity of the region involved.This suggests that no single method is satisfactory for all types and degrees of tissue defects.This prospective study was conducted in a tertiary care hospital in India,over a period of 5 years.Methods:Eighteen patients with penoscrotal defects of varying etiology were included in the study and underwent different surgical techniques.Age of the patients ranged from 20 to 60 years.The etiology of penoscrotal defect was Fournier’s gangrene in 12 cases,trauma in 4 cases,and burn in 2 cases.The patients with Fournier’s gangrene were initially treated by debridement,drainage,and antibiotics.The penoscrotal defects were treated with local flap advancement with skin grafting(n=7),pedicled anterolateral thigh flap(n=4),gracilis muscle flap with split skin grafting(n=4),and medial thigh flap(n=3).Results:There was complete healing in 16 patients with minor complications in the form of partial skin graft loss(n=1)and wound dehiscence(n=1).Results were highly satisfactory in 6 patients,satisfactory in 8 patients,and not satisfactory in 4 patients.Scarring at the donor site was limited and acceptable.Conclusion:The vast arsenal of options for penoscrotal defect coverage ranges from skin grafting to flaps,and every case needs a customized approach with regard to its feasibility,outcome,and complication rate.Flaps should be the preferred choice over the skin grafts because of the superior functional and aesthetic results and better compliance.