Kausar Ali

Postoperative Pain After Single-Site Versus Multiport Hysterectomy

Background and Objectives: With advances in laparoscopic surgery, the goal of surgeons and patients is to minimize pain to allow for faster recovery and return to normal daily activities. One of these advances is single-site surgery. In this study, we compared postoperative pain in laparoendoscopic single-site surgery (LESS) to that in traditional multiple-incision hysterectomy. Methods: Seventy patients were selected for this prospective cohort study, with 35 undergoing multiple-incision and 35 undergoing LESS hysterectomy. All patients were included who were undergoing hysterectomy with the primary surgeon. All multiport hysterectomies were performed laparoscopically. Six patients underwent LESS hysterectomy and 29 underwent robotic single-site surgery (rLESS). Patients recorded pain levels for 3 weeks after surgery on a variety of measures, including overall and incisional pain. Linear mixed effects models for repeated measures were used for all multivariate analyses, with an unstructured covariance matrix accounting for correlation between time points. Results: Overall, across all time points, there was an average reduction in pain by 1.26 (SD 0.69) points in the single-site group (P = .06). Days 3 and 14 had a marginally significant reduction in pain (P = .06 and 0.058, respectively). On days 4 and 7 there was a significant reduction in overall pain (P = .04 and .04, respectively). Conclusion: Based on the results, it is likely that single-site hysterectomy leads to less postoperative pain and achieves a lower pain score faster than multiport surgery. A randomized control trial is necessary to confirm these results before accepting them in clinical practice.

Approach to Reconstruction of Nasal Defects

Abstract The nose is the most central and anterior projecting facial feature. Therefore, the presence of a defect is easily noticeable to the untrained eye. Return of the defect to the original form is an achievable end goal of reconstruction, necessitating appropriate reformation of three‐dimensional geometry, proper establishment of symmetry, and excellent color and texture match to the adjacent structures. Regarding its physiological importance, disruption of the normal function may cause respiratory obstruction and contribute to patient distress. To achieve successful repair, preoperative preparation must consider the location, the layers involved, and the size of the defect. Prompt and well‐organized repair minimizes the occurrence of progressive necrosis and severe late‐stage deformity. Here the authors provide a framework to approach various nasal defects and provide a review of the novel ideologies and techniques. The workhorse of nasal repair, the forehead flap, is discussed independently due to the breadth of innovation.

A Randomized Control Trial for Abdominal Binder Use Following Laparoendoscopic Single Site Surgery

STUDY OBJECTIVE To compare postoperative pain in patients using an abdominal binder with a control group after laparoendoscopic single-site (LESS) surgery. DESIGN A randomized controlled trial (Canadian Task Force classification level 1). SETTING An academic gynecologic surgeons practice. PATIENTS Private patients undergoing surgery performed by a fellowship-trained minimally invasive gynecologic surgeon between April 2016 and April 2017. INTERVENTIONS Ninety total patients were selected for this study, with 60 randomized to receive an abdominal binder after surgery and 30 patients randomized to the control group without a binder. MEASUREMENTS AND MAIN RESULTS Using a 10-point verbal analog scale, patients recorded pain levels for 3 weeks postoperatively on a variety of measures, including overall and incisional pain. They recorded results on postoperative days 0, 1, 2, 3, 4, 7, 14, and 21. On average, the association between time and the overall pain score did not differ with binder use (p = .37). The overall pain decreases significantly over time (p < .001). After adjusting for time, the overall pain score differed significantly by binder status (p = .04). Those without a binder reported an average pain score that was 1.13 (standard deviation = 0.55) points higher than those with a binder across the first week. CONCLUSION The results suggest that abdominal binder use after LESS surgery may be beneficial in reducing postoperative pain in the first week. Results from this study can provide feasibility data for future studies.

Management of Panfacial Fracture

Abstract Traumatic panfacial fracture repair is one of the most complex and challenging reconstructive procedures to perform. Several principles permeate throughout literature regarding the repair of panfacial injuries in a stepwise fashion. The primary goal of management in most of these approaches is to restore the occlusal relationship at the beginning of sequential repair so that other structures can fall into alignment. Through proper positioning of the occlusion and the mandibular‐maxillary unit with the skull base, the spatial relationships and stability of midface buttresses and pillars can then be re‐established. Here, the authors outline the sequencing of panfacial fracture repair for the restoration of anatomical relationships and the optimization of functional and structural outcomes.

Total Ear Reconstruction Using Porous Polyethylene

Abstract Total ear reconstruction has been approached by several techniques involving autologous graft, prosthetic implant, and alloplastic implant options. Recent studies have shown the superiority of porous polyethylene (Medpor, Porex Surgical) reconstruction over autologous reconstruction based on improved aesthetic results, earlier age of intervention, shorter surgery times, fewer number of required procedures, and a simpler postoperative recovery process. A durable and permanent option for total ear reconstruction, like Medpor, can help alleviate the cosmetic concerns that patients with auricular deformities may be burdened with on a daily basis. In this article, the authors discuss the advantages of Medpor‐based ear reconstruction and discuss recent advances in the surgical techniques involved, such as harvesting a temporoparietal fascia flap and full‐thickness skin graft to adequately cover the Medpor framework and decrease extrusion rates.

Otologic and Audiology Concerns of Microtia Repair

Abstract Microtia is a congenital auricular deformity that commonly presents with associated congenital aural atresia. The most acute concern in these patients is concomitant hearing loss at birth. A team‐based approach by plastic surgeons and otologists is necessary to address both the otologic and audiologic concerns of microtia and atresia. Hearing rehabilitation is imperative; yet it should not compromise the aesthetic components of reconstruction and vice versa. Here, the authors propose a framework to evaluate and manage patients with microtia and atresia with the goal of optimizing functional and cosmetic outcomes.

The Protruding Ear: Cosmetic and Reconstruction

Abstract Ear prominence is a relatively common cosmetic deformity with no associated functional deficits, but with profound psychosocial impact, especially in young patients. Protruding ears in children have propagated surgical advances that incorporate reconstructive techniques. Here we outline a systematic framework to evaluate the protruding ear and present various reconstructive surgical options for correction. Both cosmetic and reconstructive perspectives should be entertained when addressing this anatomical deformity.

Review of “Opportunities for Surgical Leadership in Managing Population Health Costs” by Nathan H, Dimick JB in Ann Surg 264: 909-910, 2016

negligence of global surgery by ‘‘embedding surgery within the global health agenda, catalyzing political change, and defining scalable solutions for provisions of quality surgical and anesthesia care for all.’’ Frilling adds that this mission can be carried forward on an institutional level by partnering with programs in lowand middle-income countries to provide local training, infrastructure development, research assistance, and outcomes tracking. Furthermore, global surgery should be added to the curricula of training programs and professional societies. The developed world is plagued by its own troubles. An unfortunate reality facing these countries is the increasing death and destruction wrought by terrorist attacks. Analysis of the multiple attacks in Western Europe has shown that cooperation, professionalism, and incorporation of disaster training into medical school curriculum are vital to responding to disasters appropriately. Furthermore, more medical personnel will need training in scene triage, control centers, recognition of ‘‘war-type injuries,’’ synchronization of emergency services, and dealing with post-traumatic stress disorder. Frilling’s insightful synthesis of both global and local problems creates a framework for current and future surgeons to address the changing global landscape. Surgery will no longer be a neglected stepchild of global health but will take its rightful place as an indispensable part of health care.

Secondary Repair of Posttraumatic Enophthalmos and Extraocular Movement Disorders

Abstract Enophthalmos, or recession of the eye posteriorly and inferiorly, is a potential sequela of orbital trauma and a source of significant cosmetic and functional concern. Late enophthalmos occurs when early reconstruction of the bony orbit fails to completely restore normal orbital shape and volume, resulting in aesthetic deformity and persistent diplopia. In this article, we provide a framework for evaluation of posttraumatic enophthalmos and outline the surgical principles of secondary repair necessary to optimize globe position. With implementation of proper craniofacial exposure, osteotomy, and orbital reconstruction, surgeons may achieve significant improvement in both the aesthetic and functional sequelae of enophthalmos.