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In the gynecological literature, a limited number of studies have reported intraperitoneal bleeding due to abdominal blunt trauma. In this report, we describe a rare case of massive intraabdominal hemorrhage from the uterine artery triggered by a fall injury without apparent abdominal bruising in the presence of severe endometriosis and a uterine fibroid. A 28-year-old woman who fell from a railway platform was transported to an emergency hospital. Although she did not sustain abdominal bruising and initially had no abdominal symptoms, she complained of gradually worsening abdominal pain. Abdominal CT identified intraabdominal massive hematoma, and emergency exploratory laparoscopy revealed active bleeding from the right uterine artery eroded by endometriosis, which was treated with laparoscopic electrocoagulation. The cause of the intraabdominal bleeding was associated with avulsion of the endometriosis adhesion between the right perimetrium and the right uterine artery due to inertial forces of the uterus during the fall injury. A uterine fibroid discovered during laparoscopy was suspected to strengthen the inertial forces of the uterus. In the case of hemoperitoneum after trauma, gynecological sources of bleeding must be kept in mind, especially for patients with a known history of fibroids or endometriosis.

In patients with Roux-en-Y (RY) reconstruction for gastric resection, the newly defined "fold disruption" (FD) sign can be useful to distinguish the afferent limb from the efferent limb at the Y anastomosis when balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) is performed. The FD sign was defined as endoscopic findings of the internal folds disrupted toward the afferent limb and continued toward the efferent limb at the Y anastomosis. In this prospective observational study, the accuracy of the FD sign was evaluated for those who underwent BE-ERCP after gastric resection with RY reconstruction. Of 28 patients for whom the accuracy could be evaluated among 30 enrolled patients, the afferent limb was identified using the FD sign with 100% accuracy. For the other two patients, the scope could not reach the target lumen due to severe intestinal adhesion in one and reached the target lumen without recognition of the Y anastomosis in the other. There was no patient for whom the FD sign could not be judged for any reason, such as a blurred anastomosis line, unclear folds, sticky discharge and blood coating the surface, when the Y anastomosis was recognized. The FD sign was a highly accurate tool for distinguishing the afferent limb from the efferent limb in patients after gastric resection with RY reconstruction. This study was registered in UMIN (issued ID, UMIN000038326).

Background and objectives Bile duct injury during laparoscopic cholecystectomy has an incidence rate of 1%-2% and commonly appears under conditions of severe inflammation, adhesion, or unexpected anatomical variations. Despite the difficulties and rising concerns of identifying bile duct during surgeries, surgeons do not have a specific modality to identify bile duct except intraoperative cholangiography. While no biliary-specific fluorescent dye exists for clinical use, our team has previously described the development of a preclinical biliary-specific dye, BL-760. Here, we present our study of laparoscopic cholecystectomy using the fluorescent dye in a swine model. Study design/materials and methods With an approval from Institutional Animal Care and Use Committee, two 20-25 kg swine underwent laparoscopic abdominal surgery using a Food and Drug Administration-cleared fluorescent laparoscopic system. Images of the liver and gallbladder were taken both before and after intravenous injection of the novel fluorescent dye. The dye was dosed at 60 μg/kg and injected via the ear vein. The amount of time taken to visualize fluorescence in the biliary tract was measured. Fluorescent signal was observed after injection, and target-to-background ratio (TBR) of the biliary tract to surrounding cystic artery and liver parenchyma was measured. Results Biliary tract visualization under fluorescent laparoscopy was achieved within 5 min after the dye injection without any adverse effects. Cystic duct and extrahepatic duct were clearly visualized and identified with TBR values of 2.19 and 2.32, respectively, whereas no fluorescent signal was detected in liver. Cystic duct and artery were successfully ligated by an endoscopic clip applier with the visual assistance of highlighted biliary tract images. Laparoscopic cholecystectomy was completed within 30 min in each case without any complications. Conclusions BL-760 is a novel preclinical fluorescent dye useful for intraoperative identification and visualization of biliary tract. Such fluorescent dye that is exclusively metabolized by liver and rapidly excreted into biliary tract would be beneficial for all types of hepato-biliary surgeries. With the validation of additional preclinical data, this novel dye has potential to be a valuable tool to prevent any iatrogenic biliary injuries and/or bile leaks during laparoscopic abdominal and liver surgeries.

A median sternotomy is often performed in patients with gastric tube cancer reconstructed through the retrosternal route; however, this procedure is invasive and has the risk of severe infectious complications. To overcome these problems, we created a novel method to perform the reconstructed gastric tube resection using a gastric tube inversion technique combined with a laparoscopic mediastinal approach. After the duodenum was divided, the oral side of the cut end was sutured with silken threads for traction. The gastric tube was dissected from the caudal side under a laparoscopic mediastinal approach, whereas the cervical esophagus was taped. After the adhesion between the middle side of the posterior sternum and the reconstructed gastric tube was dissected to the cervix, the gastric tube was inverted by guiding and pulling the thread toward the cervical side. Sharp dissection was facilitated between the inverted gastric tube and the surrounding organs under moderate traction and a favorable surgical view. We have performed this procedure and evaluated the short‐term outcomes in six cases. The laparoscopic mediastinal approach was completed without a median sternotomy in all six cases. Restorable intraoperative lung injury was observed in one case and no major vessel injuries were observed. The postoperative course was satisfactory with a 29.5‐day median length of hospital stay (range, 16‐60 days). The gastric tube inversion technique combined with the laparoscopic mediastinal approach for patients with retrosternal‐reconstructed gastric tube cancer was shown to be safe and less invasive and should be considered in resection of the reconstructed gastric tube., We created the novel gastric tube inversion technique combined with laparoscopic mediastinal approach in gastric tube resection for the gastric tube cancer reconstructed through the retrosternal route. This approach is less invasive and safe, thereby avoiding the risk of serious complication associated with median sternotomy. Moreover, the gastric tube inversion technique helped to secure a sufficient working space in a narrow operation field and allows for safe dissection under favorable surgical view.

Introduction To describe laparoendoscopic single-site simple nephrectomy and reduced port simple nephrectomy for inflammatory nonfunctioning kidney. Case presentation Case 1: a 58-year-old female with fever was referred to our hospital. Computed tomography demonstrated a markedly atrophic right kidney and mild hydronephrosis. Case 2: a 64-year-old male with a history of several intra-abdominal surgeries visited our hospital with a complaint of left back pain and fever. Computed tomography demonstrated left marked hydronephrosis, thinning of renal parenchyma, and duplicated inferior vena cava. After antibiotic treatment, transperitoneal reduced port simple nephrectomy and retroperitoneal laparoendoscopic single-site simple nephrectomy were performed in Case 1 and 2, respectively, because the function of the affected kidney was almost lost on renography. Although adhesion was slightly noted around the renal hilum in Case 1, neither conversion to laparotomy nor placement of additional ports was needed. Conclusion Laparoendoscopic single-site simple nephrectomy and reduced port simple nephrectomy for inflammatory nonfunctioning kidney may be options for experienced laparoscopic surgeons.

AIM This study aimed to investigate whether subcutaneous tissue stiffness of the previous cesarean section (CS) skin incision could predict the severity of the intra-abdominal adhesions at a repeat CS. METHODS In this prospective cross-sectional study, pregnant women with at least one prior cesarean delivery were included. The subcutaneous tissue stiffness of the previous CS skin scar was measured by shear wave elastography (SWE) on the day of the repeat CS and the intra-abdominal adhesions were recorded by an adhesion classification scheme specific for CS. Total adhesion score was classified as mild adhesion between 1 and 4, moderate adhesion between 5 and 12, and severe adhesion if ≥13. RESULTS Of the 102 women, 41 (40.2%) had no adhesions, 18 (17.6%) had mild adhesions, 26 (25.5%) had moderate adhesions and 17 (16.7%) had severe adhesions. The mean SWE measurements were significantly higher in the moderate and severe adhesion group than the non-adhesion and mild adhesion group (51.5 ± 25.3 vs 36.8 ± 22.6, P = 0.003). There was a statistically significant correlation between the preoperative SWE measurements and total adhesion scores (correlation coefficient [r] = 0.397, P

Objectives To evaluate the incidence and risk factors of heterotopic ossification (HO) after arthroscopic elbow release. Methods The present study included 101 elbows, with arthroscopic release performed on 98 patients over the 5‐year period from November 2011 to December 2015. Patients were divided into three groups: group 1, with elbow arthritis, including 46 elbows in 43 patients; group 2, with posttraumatic extrinsic elbow stiffness (without intraarticular adhesion), including 23 elbows in 23 patients; and group 3, with intrinsic contractures (with intraarticular adhesion), including 32 elbows in 32 patients. Arthroscopic elbow release was performed under general anesthesia. For intrinsic stiffness, a radiofrequency device was applied to release intraarticular scar tissue and create work space, which was rarely necessary in groups 1 and 2. In the postoperative period, X‐rays and CT scans were assessed at follow up to determine if there was HO formation, which was diagnosed when new calcifications were identified. The functional recovery was evaluated by comparing the range of motion (ROM) and pain relief preoperativley and postoperatively in each group. Other complications were also assessed postoperatively. Results The patients’ mean age was 38.6 years (range, 12–66), with 57 males and 41 females. Mean follow‐up was 21 months (range, 4–56). The active ROM and Mayo elbow performance index (MEPS) were improved from 93° ± 8.3° to 126° ± 12.4° (P, The occurrence of heterotopic ossification(HO) after arthroscopic elbow release is unexpectedly high in our practice. Suspicious risk factors relate to these HO formation was investigated in this study.

Remote-access total endoscopic thyroidectomy (TET) is a recently established approach that can avoid producing scars in the neck. There are no clear surgical indications for TET for benign nodules or for malignant tumors at present. We report a successful TET in a 50-year-old Japanese woman with follicular lymphoma of the thyroid gland after an open neck biopsy. She had been referred to us with a neck tumor noted 2 months earlier. Because of adhesion, we performed a combined resection of the thyroid and partial right sternohyoid muscle. To the best of our knowledge, there is no other report of a TET performed after open neck surgery. Our patient's case demonstrates that (a) the cosmetic outcome of TET is clearly superior to that of conventional open neck surgery, and (b) a TET can be suitable even for reoperation if carefully selected.

OBJECTIVES Duodenal endoscopic submucosal dissection (ESD) for superficial non-ampullary duodenal epithelial tumors has a significant incidence rate of delayed perforation. Although several methods have been proposed to prevent delayed perforation, the most appropriate methods remain unclear. Currently, there is no appropriate animal model to validate methods for preventing duodenal delayed perforation. This study aimed to establish an in-vivo porcine delayed perforation model after duodenal submucosal dissection. METHODS Two porcine models underwent either ESD or surgical submucosal dissection. In the surgical dissection model, an inverted duodenal mucosa was resected with electrosurgical energy. In the ESD model, a gauze was placed behind the duodenum with grasped transverse part to improve endoscopic maneuverability. The mucosal defects after dissection were treated with omental coverage without suture in both models. All models were euthanized 0-5 days after procedure. Body weight; resection size; procedure dissection time; presence of intraoperative perforation and delayed perforation; and adhesion score were assessed. RESULTS There were no significant differences in body weight and adhesion score between the two models. Resection size was significantly larger in the surgical dissection models than in the ESD models (19 mm vs 14.3 mm, P

Recurrence of liver cancers inside the liver are often treated with liver resection (LR). However, increased risks of complications and conversion during operation were reported in laparoscopic repeat LR (LRLR). The indication is still controversial. One multi‐institutional propensity score matching analysis of LRLR vs open repeat LR for hepatocellular carcinoma, two propensity score matching analyses for colorectal metastases, and two meta‐analyses including hepatocellular carcinoma, intrahepatic cholangiocarcinoma, metastases, and other tumors have been reported to date. LRLR was reported with better to comparable short‐term and similar long‐term outcomes. Furthermore, the shorter operation time and the smaller amount of intraoperative bleeding for LRLR was reported for the patients who had undergone laparoscopic rather than open LR as an earlier procedure. The speculations are presented, that complete dissection of adhesion can be dodged and laparoscopic minor repeated LR can minimize the liver functional deterioration in cirrhotic patients. LRLR, as a powerful local therapy, could contribute to the long‐term outcomes of those with deteriorated liver function. However, the procedure is now in its developing stage worldwide and further accumulation of experiences and evaluation are needed., One multi‐institutional propensity score matching analysis of LRLR vs open repeat LR for hepatocellular carcinoma, two propensity score matching analyses for colorectal metastases, and two meta‐analyses including hepatocellular carcinoma, intrahepatic cholangiocarcinoma, metastases, and other tumors have been reported to date. The speculations are presented that complete dissection of adhesion can be dodged and laparoscopic minor repeated LR can minimized liver functional deterioration in cirrhotic patients. LRLR, as a powerful local therapy, could contribute the long‐term outcomes of those with deteriorated liver function. However, the procedure is now in its developing stage worldwide and further accumulation of experiences and evaluation are needed.

Remoras are fishes that attach to a broad range of hosts using an adhesive disc on their head that is derived from dorsal fin elements. Research on the adhesive mechanism of remoras has focused primarily on the skeletal components of the disc and their contribution to generating suction and friction. However, the soft tissues of the disc, such as the soft lip surrounding the bony disc and the muscles that control the bony lamellae, have been largely ignored. To understand the sealing mechanism of the disc, it is imperative to understand the tissue morphology and material properties of the soft lip. Here, we show that the soft lip surrounding the remora disc is comprised of discrete multilayered collagen, fat, and elastic tissues which we hypothesize to have specific roles in the viscoelastic sealing mechanism of the remora disc. The central, heavily vascularized fat and collagen layer are infiltrated by strands of elastic tissue and surrounded by crossed-fiber collagen. A newly described jubilee muscle underneath the adhesive disc provides a mechanism for stopping venous return from the disc lip, thereby allowing it to become engorged and create a pressurized fit to the attachment substrate. Thus, the remora lip acts as a vascular hydrostat.

Uterine ruptures typically occur suddenly, have obvious symptoms, and may require urgent treatment. We experienced a case of complete rupture of an unscarred uterus that was undetected for 9 days. We report the clinical course and possible factors that led to it. Nine days after delivery, complete rupture of the posterior uterine wall was diagnosed by magnetic resonance imaging. The colon and ovaries were tightly adhered to the posterior uterine body. When this adhesive lesion was detached, 7 cm horizontal defects of the muscular layer were revealed. The ruptured wound was repaired. Magnetic resonance imaging 1 year postoperatively showed no thinning of the repaired lesion and suggested successful reperfusion. Mild clinical course despite complete uterine rupture was presumably because of adhesion of the ovaries and intestines to the rupture site.

A 74-year-old man presented for surgical treatment to alleviate chronic post-herniorrhaphy inguinal pain. Physical and imaging examinations suggested that his pain was due to his ilioinguinal nerve being entrapped by a meshoma composed of bilayer mesh and plug mesh. The patient strongly desired mesh removal, although it appeared challenging because of adhesion of the meshes from the previous herniorrhaphies. Anticipating technical difficulty, we performed laparoscopic totally extraperitoneal repair followed by open mesh removal. Thus, the risk of damaging the peritoneum and visceral organs during open mesh removal was eliminated because the peritoneum had already been separated from the pathogenic mesh during the laparoscopic repair. The patient's chronic pain was drastically relieved. Combination surgery may therefore be a safe and useful technique in select patients with chronic postoperative inguinal pain. This approach could also prevent hernia recurrence.

Background Repeat hepatectomy (ReHx) for recurrent hepatic malignancies reportedly provides oncological benefit for patients. However, severe adhesions at the time of ReHx may preclude safe and curative resection and there has been no reliable measure to estimate the surgical risk at ReHx. This study sought to create a new scoring system for evaluating the severity of adhesion after hepatectomy and tested its performance looking at the correlation with morbidity rate. Methods Operative videos of 66 patients undergoing a second hepatectomy were reviewed and the difficulty levels in lysis of adhesion around the hepatic hilum (A score) and surrounding the liver (B score) were scored by two examiners and validated by two additional reviewers. Results Very high interobserver agreement was confirmed between the two examiners (κ value, 0.960-0.963) and reproducibility of results were validated with weighted kappa values of >0.8 in both surgical resident and hepatobiliary surgeon. Linear correlation was confirmed between the difficulty score and postoperative morbidity rate. Multivariate analyses confirmed that previous cholecystectomy or transection of visceral surface of segment 4 or 5 was an independent factor predicting hard to extreme adhesions at the hepatic hilum regardless of the use of anti-adhesion materials. Conclusions The new difficulty scoring system for the lysis of adhesion at ReHx showed good interobserver agreement and reproducibility of the results. Given the strong correlation with postoperative morbidity rate, the present score could be used for evaluating the technical difficulties in ReHx and may offer a reliable measure for estimating the efficacy of anti-adhesion materials in future analysis.

Aim To investigate the accuracy and clinical value of an adhesion scoring system using transvaginal ultrasonography for endometriotic adhesion. Methods In this prospective observational study, we included 131 patients with endometriosis who underwent surgery. Before surgery, transvaginal ultrasonography and adhesion mapping were performed to determine the presence or absence of adhesions at 10 sites of the pelvis. Mapping accuracy was determined by comparing the mapping findings with the surgical findings. To determine the severity of pelvic adhesions, we developed an adhesion score (0-10). With the adhesion score, we assessed the effect of surgical adhesiolysis and evaluated the relationship between postoperative adhesions and infertility. Results Of the 10 sites assessed for adhesions, the most frequent site of adhesions was the site between the left ovary and the uterus (70.5%). The overall sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and accuracy of adhesion mapping were 80.4%, 86.1%, 78.8%, 87.2%, 5.79, 0.23 and 83.9%, respectively. The adhesion score in this system was significantly correlated with the adhesion-related score in the revised American Society for Reproductive Medicine classification (R2 = 0.734). Surgical adhesiolysis yielded only about 30% improvement postoperatively. The adhesion score 1 month after surgery in the non-in vitro fertilization (IVF) pregnancy group was significantly lower than that in the IVF pregnancy group (3.45 vs 5.21; P = 0.02). Conclusion Our adhesion scoring system allowed an accurate prediction of the pelvic adhesion status and may potentially be an indicator of postoperative adhesions and infertility.

Although achieving the critical view of safety (CVS) is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy (LC), the CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. Herein, we focused on segment IV of the liver and its diagonal line (D‐line) as a feasible landmark for carrying out difficult LC. The D‐line connects the right dorsal and left ventral corners of segment IV and is used as the vectoral landmark, which is where the gallbladder is first dissected to achieve CVS without misidentification. Conversion to subtotal cholecystectomy along the D‐line is also feasible when gallbladder wall scarring is severe. We named this procedure the segment IV approach for LC. Sixty‐two consecutive difficult LC (including 27 scheduled LC after percutaneous transhepatic gallbladder drainage [PTGBD] and 35 conservatively treated cases of Tokyo Guidelines [TG] grade II cholecystitis) were managed by the segment IV approach. Successful gallbladder extraction along the D‐line was achieved in 44 (71%) cases; all of these cases also achieved CVS following total cholecystectomy. The other 18 (29%) cases were converted to subtotal cholecystectomy because gallbladder extraction along the D‐line failed as a result of severe cholecystitis with inflammatory adhesion with surrounding structures. Median operative time and intraoperative blood loss were 135 (range, 54‐290) min and 10 (range, 0‐100) mL, respectively. No intra‐ or postoperative complications were observed. The segment IV approach is feasible for achieving CVS and for considering subtotal cholecystectomy in difficult LC cases where scarring of the gallbladder wall is present., Schematic demonstrations of the segment IV approach. Under physiological conditions, the D‐line runs to the right border of the Hiller plate. Condition where the cystic plate is thickened and shrinking is caused by gallstones. The positional relationship between the D‐line, with respect to the Hiller plate, remains unchanged.

Background Tonsils are first-line host defence organs against pathogenic agents and participate in local and systemic immunity. Persistent increases in systemic inflammatory responses may contribute to associated morbidity. The aim of this study was to verify the short- and long-term impact of adenotonsillectomy on the evolution of inflammatory markers in 3- to 9-year-old children. Methods A prospective and longitudinal study was conducted over 1 year in 29 children who underwent tonsillectomy due to either chronic tonsillitis or adenotonsillar hypertrophy. Measurements of high-sensitivity C-reactive protein (hs-CRP) levels were taken. Levels of Th1-type cytokines [interleukin-1, interferon-γ, and tumor necrosis factor-I± (TNF-α)] and anti-inflammatory Th2-type cytokines [interleukin-4, -5, -6, -10 and -13] were measured. Levels of transforming growth factor-beta (TGF-β) and intercellular adhesion molecule-1 (ICAM-1) were also determined. The results were compared to those of 29 control children. Results At baseline, children with surgery indications presented with higher levels of hs-CRP, interleukin-1 and -10, interferon-γ, TNF-α and ICAM-1, whereas values of interleukin-4 were significantly lower than in control children. Children with severe tonsillar obstruction had higher values of interleukin-1, -4, and -5 and lower values of interleukin-10 compared with children with recurrent tonsillitis. One year after surgery, the levels except IL-4 did not show a significant difference from those obtained in the control group. The levels of hs-CRP and TNF-α decreased significantly in the first month. Conclusion Children with chronic tonsillitis and/or adenotonsillar hypertrophy have significantly elevated levels of proinflammatory cytokines. Adenotonsillectomy restores the normal values of these parameters 1 year after surgery.

Purpose To evaluate the efficacy of silicone sheet as a new type of barrier for preventing adhesion reformation following hysteroscopic adhesiolysis of intrauterine adhesions (IUAs). Methods Hysteroscopic adhesiolysis was performed for 36 patients with IUAs. The adhesion reformation rate was retrospectively compared between 26 patients treated with silicone sheet (group 1) and 10 patients treated with an intrauterine device wrapped in oxidized regenerated cellulose as a barrier (group 2). For patients in group 1, a 1‐mm‐thick silicone sheet was cut to fit the size and shape of the individual uterine cavity as a personalized barrier. Results The size and shape of each silicone sheet used for patients in group 1 differed significantly. The adhesion reformation rate was significantly lower in group 1 (4/26, 15.4%) than in group 2 (4/10, 40.0%; P = 0.03), although the pregnancy rate (14/20, 70.0% vs. 5/10, 50.0%; P = 0.28) and miscarriage rate (2/14, 14.3% vs. 1/5, 20.0%; P = 0.72) were not significantly different. Conclusion Use of silicone sheets appears to be effective for preventing adhesion reformation following hysteroscopic adhesiolysis of IUAs. This is the first study to investigate the efficacy of silicone sheet used as a personalized barrier for preventing IUAs.

Introduction This study aimed to investigate the predictive factors and classifications for difficulty of laparoscopic repeated liver resection (LRLR) in patients with recurrent hepatocellular carcinoma. Methods Sixty patients who underwent LRLR were included. Potential predictive factors for difficult LRLR included the approach of the previous liver resection (laparoscopic or open), the number of previous liver resections, a history of cholecystectomy in previous liver resection, the operative procedure of previous liver resection, whether the tumor was near the resected site of the previous liver resection, non-surgical treatments before the present surgery, and the difficulty scoring system for laparoscopic liver resection. The relationship between these factors and perioperative outcomes were evaluated to investigate the predictive factor for difficult LRLR. Results Univariate and multivariate analyses demonstrated that an open approach during previous liver resection, two or more previous liver resections, a history of previous liver resection with not less than sectionectomy, tumor near the resected site of the previous liver resection, and intermediate or high difficulty in the difficulty scoring system were independent risk factors for prolonged operative time and/or severe adhesion of LRLR. Three difficulty classifications were then suggested based on the number of these five predictive factors. The difficulty classification reflected operative time, intraoperative blood loss, and incidence of postoperative complication. Conclusion The difficulty of LRLR may be predicted by three difficulty classifications using five preoperative predictive factors.

Background Seprafilm did not decrease small bowel obstruction (SBO), but significantly decreased reoperation in patients with inflammatory bowel disease. However, the preventive effect in colon cancer remains unclear. Methods We conducted a randomized controlled trial in patients with colon cancer. The study group comprised 345 patients with colon cancer. In the seprafilm group (n = 166), two sheets of seprafilm were inserted under a midline incision. Patients who were admitted and required decompression were considered to have SBO. Results The median follow-up was 61.9 months. Patient characteristics were well balanced. There was no significant difference in the incidence of SBO between the seprafilm group (7.8%) and the control group (10.6%) (P = .46). In patients who underwent reoperation, SBO occurred in a midline incision in one patient and at other sites in four patients in the seprafilm group as compared with two patients and five patients, respectively, in the control group. Multivariate analysis showed that only a history of laparotomy was an independent risk factor for SBO. Conclusions Seprafilm did not decrease SBO or reoperation in colon cancer. The incidence of SBO caused by adhesion to the midline incision was relatively low as compared with that caused by adhesion to other sites.

A reinforced tubular, medicated electrospun construct was developed for deep flexor tendon repair. This construct combines mechanical strength with the release of anti-inflammatory and anti-adhesion drugs. In this study, the reinforced construct was evaluated using a rabbit model. It was compared to its components (a tubular, medicated electrospun polymer without reinforcement and a tubular braid as such) on the one hand to a modified Kessler suture as a control group. Forty New Zealand rabbits were randomly divided into two groups. Surgery was performed in the second and fourth deep flexor tendons of one hind paw of the rabbits in the two groups using four repair techniques. Biomechanical tensile testing and macroscopic and histological evaluations were performed at 3 and 8 weeks postoperatively. A two-way analysis of variance with pairwise comparisons revealed that the three experimental surgical techniques (a reinforced tubular medicated electrospun construct, tubular-medicated construct, and tubular braid as such) showed similar strength as that of a modified Kessler suture repair, which was characterized by a mean load at ultimate failure of 19.85 N (standard deviation [SD] 5.29 N) at 3 weeks and 18.15 N (SD 8.01 N) at 8 weeks. Macroscopically, a significantly different adhesion pattern was observed at the suture knots, either centrally or peripherally, depending on the technique. Histologically, a qualitative assessment showed good to excellent repair at the tendon repair site, irrespective of the applied technique. This study demonstrates that mechanical and biological repair strategies for flexor tendon repair can be successfully combined. ispartof: JOURNAL OF ORTHOPAEDIC RESEARCH vol:40 issue:3 pages:750-760 ispartof: location:United States status: published

Histological biomarkers are one of the most advantageous tools in monitoring toxicological studies under experimental condition in laboratory. Since disinfectants are extensively inflowing into aquatic ecosystems, this study conducted on common carp to examine the effect of betadine solution on the liver and gill tissue. A 120-carp were kept for 2 weeks in the 100-l aquarium Different concentrations of povidone-iodine (betadine) prepared in three replications and a control group was prepared with no betadine (0, 5, 7, 8, and 9 ppm). Most lesions observed at gill tissue include adhesion secondary lamella, bleeding, destruction of secondary lamellae, hyperplasia secondary blades, curvature second blade, destroying the primary lamellae. Whats more, most lesions observed in liver tissue include bleeding, ascites liver, destruction of liver cells, bile stagnation. Betadine solution, could cause damage to the liver and gills tissues, although gill lesions were more evident than liver. Also increase of concentration led to elevation at lesions of both organs. Overally, the results revealed that using povidon-iodine as a disinfectant materials and entering into rivers and aquatic ecosystems could have undesirable effects and even death of this fish. Disinfectants, either in low or high concentration, could be very lethal for fish. However the defects seen in this study also could affect osmoregulation and metabolism as two main functions of gill and liver.

BACKGROUND Various adjuvant therapies have failed to improve clinical symptoms and pregnancy rates among patients with moderate-to-severe intrauterine adhesion. OBJECTIVES To evaluate the ability of amniotic membrane to prevent the recurrence of intrauterine adhesion after hysteroscopic adhesiolysis. SEARCH STRATEGY The Cochrane Library, Embase, and PubMed databases were searched for articles published before December 31, 2017, using the terms: ("amnion") and ("intrauterine adhesions" or "Asherman syndrome" or "IUA" or "endometrial injury" or "uterine adhesion" or "hysteroscopic" or "hysteroscopic adhesiolysis"). SELECTION CRITERIA Randomized controlled trials of amniotic membrane therapy after hysteroscopic adhesiolysis. DATA COLLECTION AND ANALYSIS Four studies were included in the meta-analysis (300 patients in total). Dichotomous outcomes were expressed as relative risk (RR) with 95% confidence intervals (CIs). Continuous variables were expressed as mean difference. MAIN RESULTS Amniotic membrane increased menstrual blood volume after hysteroscopic adhesiolysis (mean difference 6.15, 95% CI 4.20-8.11; P

BACKGROUND Ipsilateral pulmonary reoperation is empirically considered a contraindication of video-assisted thoracic surgery (VATS) because of intrapleural adhesion and the destruction of anatomical structures caused by previous surgery. The purpose of this study was to present our experience of the use of VATS for ipsilateral reoperations. METHODS The medical records of patients who underwent VATS reoperation or re-thoracotomy between January 2006 and March 2017 were retrospectively reviewed. Data were compared to assess the feasibility and safety of VATS for ipsilateral reoperations. RESULTS The study enrolled 64 patients, including 36 patients who underwent attempted ipsilateral VATS reoperations (VATS group) and 28 who underwent conventional re-thoracotomy as a control with clinicopathological characteristics similar to those in the VATS group. Intrapleural severe adhesions were detected in 28 (77.8%) and 22 (78.6%) patients in the VATS and re-thoracotomy groups, respectively (P = 0.906), and their dissection required a longer period in the VATS group (P = 0.014). VATS reoperations were converted to re-thoracotomy or video-assisted mini re-thoracotomy in three patients because of bleeding or difficulty in dissecting hilar structures. There were no significant differences in resection methods, time to reoperation, intraoperative blood loss, or drainage time between the two groups. However, patients in the VATS group had a shorter hospital stay (P < 0.01) and fewer complications (P = 0.042). CONCLUSION VATS is an optimal alternative to re-thoracotomy for ipsilateral pulmonary lesions, regardless of intrapleural adhesions and the destruction of anatomical structures caused by former operations in selected patients.

A 44-year-old multipara woman was referred because of the sudden onset of left lower abdominal pain. Corpus luteum hematoma was suspected and conservatively managed. Two days later, due to worsening of abdominal symptoms, emergency laparoscopic surgery was performed. Severe pelvic adhesion around the left ovary forming corpus luteum hematoma was identified. After adhesiolysis, which was complicated by massive bleeding, left adnexectomy was performed. Hemostasis was achieved by the coagulation of bleeding vessels, followed by spraying fibrin glue with the placement of oxidized cellulose cotton for bleeding oozing from dissected surface. Two hours after surgery, emergency computed tomography performed due to the development of hemodynamic instability demonstrated extravasation from the versa recta of the sigmoid artery. After the confirmation of hemorrhaging, superselective catheterization to the bleeding vessel followed by embolization by platinum microcoils were performed. Hemodynamic stability was immediately achieved, and the postoperative course was uneventful without manifestation of bowel ischemia.

Flexor tendon injuries are common and pose a clinical challenge for functional restoration. The purpose of our study was to assess the adequacy of the turkey as a large animal model for flexor tendon injuries in vivo. Twenty-four male turkeys underwent surgical flexor tendon cut and repair. Turkeys were allocated to five groups postoperatively: (1) foot casted in extension and sacrificed after 3 weeks; (2) foot casted in extension and sacrificed after 6 weeks; (3) foot casted in flexion and sacrificed after 3 weeks; (4) foot casted in flexion and sacrificed after 6 weeks; and (5) foot casted in flexion for 6 weeks and then free roaming allowed for an additional 3 weeks before sacrifice. After sacrifice, digits were collected and analyzed for adhesion formation, healing at the macrolevel and histologically, and biomechanical properties-including friction, work of flexion, stiffness, and strength of repair. All turkeys survived anesthesia and surgery. Tendon rupture occurred in all extension casts and in 11% of those casted in flexion. Friction and work of flexion were significantly higher in the repaired digit than the control digit. There was a correlation between duration of immobilization and repair strength. Histologically, the tendon healed with tenocytes migrating into the gap and producing collagen fibers. We have, for the first time, studied flexor tendon injury and repair using turkeys in terms of anesthesia, surgical procedures, postoperative care, and animal husbandry. The findings regarding functional and histological results from this novel avian model were comparable to the most commonly used mammal model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2497-2505, 2018.

This study was to test our hypothesis that flexor tendon reconstruction with an allograft revitalized with bone marrow stromal cells (BMSCs) and synovialized with carbodiimide derivatized autologous synovial fluid (cd-SYN) would result in better digit functional restoration than the conventional allograft tendon. A total of 32 flexor digital profundus tendons from the second and fifth digit of 16 dogs were created a repair failure model first. Then, failed-repaired tendons were reconstructed with either a revitalized-synovialized allograft tendon or a clinical standard autograft tendon (control group). The allograft tendon was seeded with autologous BMSCs in multiple slits and the graft surface was coated with cd-SYN. A 6 weeks after tendon reconstruction, the digits were harvested and evaluated for digit function, adhesion status, tendon gliding resistance, attachment strength, cell viability, and histologic factors. The allograft group had significantly improved digit function compared with the control group through decreased work of flexion, increased digit range of motion under 2-Newton force, and less adhesion score (p

OBJECTIVES The tissue motion of annular displacement provides an accurate and rapid assessment of left ventricular (LV) systolic function. However, it has rarely been used in patients with chronic constrictive pericarditis and restrictive cardiomyopathy. This study aimed to assess the differences in LV systolic function in patients with constrictive pericarditis and restrictive cardiomyopathy using tissue motion of annular displacement derived from speckle-tracking echocardiography. METHODS Twenty-four patients with constrictive pericarditis, 24 with restrictive cardiomyopathy, and 25 healthy volunteers (controls) were enrolled. The septal and lateral mitral annular longitudinal displacements, displacement at the midpoint, and normalized midpoint displacement of the mitral ring were calculated. RESULTS Mitral annular tracking and quantification of the tissue motion of annular displacement were achieved within 10 seconds. In patients with constrictive pericarditis, the lateral mitral annular longitudinal displacement, displacement at the midpoint, and midpoint displacement of the mitral ring were decreased, whereas the septal mitral annular longitudinal displacement was preserved compared to controls, indicating that the reduction of systolic function in constrictive pericarditis was caused by pericardial adhesion and calcium. In patients with restrictive cardiomyopathy, tissue motion of annular displacement was more reduced compared to patients with constrictive pericarditis and controls. The correlation between the septal mitral annular longitudinal displacement and left ventricular ejection fraction was 0.67 (P

Complete surgical resection of chronic expanding intrapericardial hematoma was often difficult because of the severe adhesion. Preoperative coil embolization of the feeding vessels can prevent recurrent expanding of the residual hematoma and would achieve good results.

Deep infiltrating endometriosis (DIE) is the most severe form of endometriosis. It causes chronic pelvic pain, severe dysmenorrhea, deep dyspareunia, dyschezia, and dysuria, markedly impairing the quality of life of women of reproductive age. A number of randomized controlled trials on surgical and medical treatments to reduce the pain associated with endometriosis have been reported, but few have focused on this in DIE. DIE causes not only pain but also functional invasion to the urinary organs and bowel, such as hydronephrosis and bowel stenosis. In addition to DIE resection, surgical treatment involves adhesion separation as well as resection and reconstruction of the urinary organs and bowel; high-level skills are required. The severity of DIE should be evaluated preoperatively as accurately as possible. Using ENZIAN in conjunction with the AFS (The revised American Fertility Society classification of endometriosis) classification makes a more detailed assessment of DIE possible. The operative procedures used for laparoscopic resection of urinary DIE and reconstruction of the urinary organs are chosen based on the type of lesion (intrinsic/extrinsic) and length of stenosis. In addition to ureteroneocystostomy, the psoas bladder hitch and Boari bladder flap procedures are applied when necessary to extend the urinary tract. Bowel resection for bowel endometriosis is classified into classic segmental resection and conservative approaches (shaving/discoid). When these procedures are employed, it is advisable to work in consultation with urologists and gastroenterologists and to inform the patients of the associated risks and outcomes. Furthermore, postoperative medication is essential because it is difficult to conduct repeated surgeries.

BACKGROUND Adhesion formation and ostial stenosis are common causes of surgical failure after endoscopic sinus surgery (ESS). Postoperative topical steroid application has been shown to improve wound healing. Chitosan-dextran gel (CD gel) is an effective hemostatic nasal dressing. This study aims to determine the effect of the addition of budesonide to CD gel on postoperative ostial stenosis and adhesion formation following ESS. METHODS This prospective, blinded, randomized controlled trial was conducted between October 2012 and April 2015. Thirty-six patients over 18 years undergoing ESS were randomized to receive either: no treatment, CD gel, CD gel with 1 mg/ 2 mL budesonide, or topical steroid cream to their left or right sinuses (different treatment each side). Each sinus ostium and endoscopic features of wound healing was measured intraoperation, and 2 weeks, 3 months, and 12 months postoperation. RESULTS Data was analyzed using the analysis of variance (ANOVA) and post hoc Tukey honestly significant difference (HSD) tests. There was a significant reduction in stenosis within all 3 sinuses ostia sites when CD + budesonide was compared to control, with the greatest effect seen at 12 months: The mean ± standard deviation (SD) percentage of baseline areas at 12 months were 76% ± 6.2% vs 37% ± 23.5%, 76% ± 6.3% vs 52% ± 4.9%, and 83% ± 6.5% vs 58% ± 5.0% (all p < 0.05), for CD + budesonide compared to control in the frontal, sphenoid, and maxillary sinuses, respectively. The incidence of adhesions was 4% in the CD + budesonide group compared to 15% in the control group. CONCLUSION This study has shown that CD gel, when combined with topical budesonide solution, improves long-term sinus ostial patency and prevents ostial stenosis post-ESS.

Perineal hernia (PH) is a rare complication following laparoscopic abdominoperineal resection (APR) for rectal cancer. We present a case report of perineal hernia after laparoscopic APR and discuss its management. The patient was a 77-year-old man who was diagnosed with lower rectal cancer. He underwent laparoscopic APR and bilateral lateral lymph node dissection. Two months after the surgery, pain and bulging in the perineal region developed, and PH was diagnosed by CT. Repair with a polypropylene mesh was performed using a combination of laparoscopic abdominal and transperineal approaches. Reportedly, the incidence of secondary PH after APR has increased along with the rate of laparoscopic surgery. Treatment of secondary PH with transperineal repair alone may cause injuries to other organs because of adhesion of the pelvic viscera. In the present case, we safely repaired the hernia repair using a laparoscopy-assisted perineal approach.

Background Use of absorbable packing materials after functional endoscopic sinus surgery (FESS) is associated with increased patient comfort and a lack of need for packing removal. Different materials may induce different patterns of mucosal healing and hemostasis. This study investigated the effect of fibrin sealant (FS; Tisseel) or biodegradable synthetic polyurethane foam (Nasopore®) packing on hemostasis and wound healing after FESS. Methods This prospective randomized controlled trial included 35 consecutive patients who underwent bilateral FESS for chronic rhinosinusitis. The patients were randomized to receive FS through aerosol spraying on 1 side and Nasopore packing on the opposite side. They were followed at 1, 2, 4, 8, and 12 weeks after surgery. Endoscopically visible packing material, crusting, adhesion, bleeding, granulation tissue formation, frontal sinus patency, and adverse effects were assessed. Subjective symptoms related to nasal packing were evaluated by using questionnaires quantified with a visual analogue scale. Results No significant differences were found between the FS-treated side and the Nasopore-packed side with respect to postoperative bleeding, adhesion, or frontal sinus patency. However, crusting and granulation were significantly lower in FS-treated nostrils (p < 0.01). The patients’ satisfaction and willingness to reuse the material were not significantly different between FS and Nasopore. There were no allergic reactions to either material. Conclusion FS and Nasopore were equally successful in achieving hemostasis and patient satisfaction after FESS. However, our results suggest that differential mucosal healing patterns may be induced by alternative absorbable hemostatic materials. FS-treated sides showed more optimal healing patterns than Nasopore-packed sides.

Renal injury is common in abdominal trauma. Adhesives and sealants can be used to repair and preserve damaged organs. We describe the effect of three biomaterial treatments (TachoSil, GelitaSpon, and Adhflex) on injured renal tissue. Renal traumatic injuries were experimentally induced in male Wistar rats (n = 90) using a punch. Animals were divided into five groups: (1) sham noninjured (n = 3) and punch injury groups; (2) nontreated (n = 6); (3) TachoSil (n = 27); (4) GelitaSpon (n = 27); and (5) Adhflex (n = 27). Wound healing was evaluated 2, 6, and 18 days postinjury by inflammatory cytokines response, histopathological evolution of lesions, inflammatory reaction markers (CD68), and vascular neoformation (CD31). The TachoSil group showed the least inflammatory reaction among the three treated groups, which showed similarly low inflammatory reaction 18 days postinjury. Ciliary neurotrophic factor, soluble intercellular adhesion molecule-1, L-selectin, thymus chemokine, and TIMP metallopeptidase inhibitor 1 expression peaked between 2 and 6 days postinjury. TachoSil promoted the highest cytokine expression. The Adhflex group had the highest CD31 inflammatory immune-marker levels at 2 and 6 days postinjury, but there was a similar decrease in CD31 levels in all three groups at 18 days postinjury. The results show that all three sealant treatments induced a normal healing process with the typical pattern of proinflammatory cytokine and immune-marker expression. Each tested sealant substance could be suitable treatment for renal lacerations. The findings of this study indicate that Adhflex® elastic cyanoacrylate does not induce an adverse inflammatory reaction, and therefore, could be considered as one of the first-line treatments for renal injuries. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1444-1455, 2018.

Abdominal surgery is linked with peritoneal adhesions. We investigated that the anti-fibrotic agent pirfenidone (PFD) has immune modulating activities and evaluated its effects on the function of T helper type 1 (Th1), Th2 and T regulatory (Treg) cells, which may play important roles in peritoneal adhesions. Eighteen female Wistar rats underwent right-sided parietal peritoneal and right uterine horn adhesion model. Rats were randomized into 3 groups as group 1 (control) (closure of midline abdominal incision without any agent administrations), group 2 (closure of incision after intraperitoneal administration of PFD) and group 3 (closure of incision and only oral administration of PFD for 14 days). Relaparotomy was performed 14 days after the first surgery. Effect of PFD on adhesion formation was assessed on Th1, Th2 and Treg cells counts using Anti-T-bet, Anti-GATA-3 Anti-FOXP3 antibodies respectively. Th1 counts were moderate in the control group, and didn't show a significant difference between all groups. Th2 cell counts were very high in the control group, but both intraperitoneal and oral administration of PFD resulted in a significant reduction in Th2 cell counts. Treg cell counts were low in number in the control group. In the intraperitoneal administration of PFD group, Treg cell counts were significantly lower than control group. There was no difference of the Treg cells between control groups and the oral administration of PFD group. PFD has prevention effect on intraperitoneal adhesions. This prevention effect seems to be related with the reduction in the numbers of Th2 and Treg cells. © 2017

Aim Adhesion after pelvic surgery causes infertility, ectopic pregnancy, and ileus or abdominal pain. The materials currently available for clinical use are insufficient. The purpose of this study was to develop an anti-adhesive material that overcomes the limitations of conventional anti-adhesive agents. Methods The adhesion prevention effects of three methods – a two-layered sheet composed of gelatin film and gelatin sponge, Seprafilm and INTERCEED – were evaluated in 37 dogs. Anti-adhesive effects were investigated macroscopically and microscopically in a cauterized uterus adhesion model. Cell growth on the materials in vitro using human peritoneal mesothelial cells, fibroblasts and uterine smooth muscle cells were also evaluated. Results The two-layered gelatin sheet had significantly superior anti-adhesive effects compared to the conventional materials (Seprafilm and INTERCEED). A single-cell layer of mature mesothelium formed three weeks after surgery in the gelatin group. Peritoneum regeneration in the Seprafilm and INTERCEED groups was delayed and incomplete in the early phase. Little inflammation around the materials occurred and cell growth was significantly proliferated with the gelatin sheet. Conclusion The anti-adhesive effects of a two-layered gelatin sheet were superior to conventional agents in a cauterized canine uterus model, demonstrating early regeneration of the peritoneum, little inflammation and material endurance. The newly developed two-layered gelatin sheet is a useful option as an anti-adhesive agent for deeply injured and hemorrhagic sites.

Laparoscopic repair for ventral and incisional hernias was first reported in the early 1990s. It uses intraperitoneal only mesh placement to achieve a tension-free repair of the hernia. However, in recent years, there has been greater concern about long-term complication involving intraperitoneal mesh placement. Many case reports and case series have found evidence of mesh adhesion, mesh fistulation, and mesh migration into hollow organs including the esophagus, small bowel, and large bowel, resulting in various major acute abdominal events. Subsequent management of these complications may require major surgery that is technically demanding and difficult; in such cases, laparotomy and bowel resection have often been performed. Because of these significant, but not common, adverse events, many surgeons favor open sublay repair for ventral and incisional hernias. Investigators are therefore searching for a laparoscopic approach for ventral and incisional hernias that might overcome the mesh-induced visceral complications seen after intraperitoneal only mesh placement repair. Laparoscopic preperitoneal onlay mesh is one such approach. This article will explore the fundamental of intraperitoneal only mesh placement and its problems, the currently available peritoneal visceral-compatible meshes, and upcoming developments in laparoscopic ventral and incisional hernia repair. The technical details of preperitoneal onlay mesh, as well as its potential advantages and disadvantages, will also be discussed.

Aim Laparoscopic surgery causes fewer postoperative adhesions than laparotomy and adhesion barriers are used to lessen the chance of adhesion. Sodium hyaluronate and carboxymethylcellulose (SH-CMC), a bioresorbable membrane, is effective in preventing adhesions. However, its properties make it difficult to insert the film into the abdominal cavity and to place it into the target area during laparoscopic surgeries. Here we report a novel technique for applying SH-CMC during laparoscopic surgeries by using cut-off surgical glove fingers. Methods In our dry-box experiment, we found that SH-CMC became more flexible after moisturizing for 30 s. Therefore, for this procedure, we moisturizing both sides of the SH-CMC sheet (7.35 × 6.35 cm) on wet gauze (for 30 s). The film was rolled into cut-off surgical glove fingers and inserted into the abdominal cavity through a 12-mm trocar. The film was then removed from the glove finger and unrolled onto the target area (glove-finger method). Results The dry-box experiment revealed that moisturizing both sides of SH-CMC for 30 s/side, 15 min after package removal, made the film more flexible. Ninety of 96 attempts with SH-CMC were successful among the 24 patients who underwent total laparoscopic hysterectomy with our glove-finger method. Conclusion Our glove-finger method can realize the smooth application of SH-CMC to the target area during laparoscopic surgeries.

Separating wounded serosa by physical barriers is the only clinically approved adjunct for postoperative adhesion prevention. Since the optimal adhesion barrier has not been found, it is essential to improve our pathogenic understanding of adhesion formation and to compare the effects of different barrier materials on tissue and cells. Wistar rats underwent standardized peritoneal damage and were treated either with Seprafilm, Adept, Intercoat, Spraygel, SupraSeal or remained untreated as a control. 14 days postoperatively, the lesions were explanted and histomorphologically analyzed using the European ISO score to evaluate material implants. Striking differences between the material groups were present regarding the inflammation, fibrosis, and foreign body reaction. According to the ISO score, Intercoat and Spraygel were considered as nonirritating to tissue. Adept, Seprafilm, and SupraSeal were assessed as mild-irritating materials. Interestingly, the most effective material in adhesion prevention revealed moderate inflammation accompanied by minor fibrosis. The degree of inflammation to barrier materials does not predict the efficacy in the prevention of adhesions. Histopathological investigations are crucial to improve our understanding of the cellular mechanisms during adhesion formation and elucidate the tissue response to material approaches used in adhesion prevention. This will lead to improved antiadhesive strategies and the development of functional barrier biomaterials. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 598-609, 2018.

Small bowel obstruction (SBO) accounts for 12–16% of emergency surgical admissions and 20% of emergency surgical procedures. Even with the advent of laparoscopic surgery, intra‐abdominal adhesions remain a significant cause of SBO, accounting for 65% of cases. History and physical examination are essential to identify signs of bowel ischemia as this indicates a need for urgent surgical exploration. Another critical aspect of evaluation includes establishing the underlying cause for obstruction and distinguishing between adhesive and non‐adhesive etiologies as adhesive SBO (ASBO) can be managed non‐operatively in 70–90% of patients. A patient with a history of abdominopelvic surgery along with one or more cardinal features of obstruction should be suspected to have ASBO until proven otherwise. Triad of severe pain, pain out of proportion to the clinical findings, and presence of an abdominal scar suggest possible closed‐loop obstruction. Computed tomography has higher sensitivity and specificity compared to plain films and is recommended by the Bologna guidelines. Correcting fluid and electrolyte imbalance is an initial crucial step to mitigate severe hypovolemia. Patients should proceed with surgery if symptoms of bowel compromise are present, or if symptoms do not resolve or have worsened. Surgery is indicated in patients with ischemia, strangulation, perforation, peritonitis, or failure of non‐operative treatment. With advances in minimal access technology and increasing experience, laparoscopic adhesiolysis is recommended. Mechanical adhesion barriers are an effective measure to prevent adhesion formation., Even with the advent of laparoscopic surgery, intra‐abdominal adhesions remain a significant cause of small bowel obstruction, accounting for 65% of cases. History and physical examination are essential to identify signs of bowel ischemia as this indicates a need for urgent surgical exploration. Elective non‐operative management has a success rate of 70–90% in patients with adhesive small bowel obstruction.

Current treatment methods to repair meniscal tears do not bring fully satisfactory results. Tissue adhesives are considered promising alternatives, since they are easy to apply and cause minimal tissue trauma. The first aim of this study was to analyze the adhesive properties of and tissue response to two recently developed biodegradable block copolymeric three-armed- and hyper-branched tissue adhesives. The second aim was to investigate if tissue surface modification with collagenase improves the attachment of the adhesives and increases the healing potential of the tissue. Cylindrical explants were harvested from bovine menisci. The central core of the explants was removed and glued back into the defect, with or without incubation in collagenase solution prior to gluing, using one of the novel glues, Dermabond® or fibrin glue. The repair constructs were cultured in vitro for 1 and 28 days. Adhesion tests and histology were performed to analyze the effects of the glue in combination with the additional treatment. The adhesive strength of the novel glues was 40-50 kPa, which was significantly higher than that of fibrin glue (15 kPa). Cells were present in direct contact with the glues, and the tissue remained vital during the whole culture period. Increased cellularity around the tear in the collagenase treated explants was observed after 1 day. The two newly developed tissue adhesives are attractive materials to be used for repair of meniscal tears. The beneficial influence of collagenase treatment in treating meniscal tears with glues still needs to be confirmed in more clinical relevant studies. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 1405-1411, 2017.

OBJECTIVE To investigate the protective effect of autologous venous ensheathment on sutured rat facial nerve and to test whether the ensheathment could improve the functional recovery of repaired nerve and accuracy of axonal growth. STUDY DESIGN In vivo study. METHODS Forty-six rats were examined, with six rats serving as normal controls and 40 receiving facial nerve transection and suture repair (SR) or transection and suture repair with an additional venous ensheathment (VE). The rats were then subjected to functional testing, histological assessment of nerve specimens, or retrograde tracing, respectively. RESULTS At the postoperative day (POD) 60, the venous ensheathment showed no adhesion at the surrounding tissues. No significant difference in neuroma formation was found between the two surgical manipulations (SR and VE groups) (P < 0.05). Retrogradely labeled motoneurons in facial nuclei were extremely disorganized after the facial nerve undertook surgical manipulation. In all manipulated groups, double retrogradely labeled neurons, indicative of aberrant axonal branching during regeneration, could be observed after peripheral manipulation across all time points. With the two facial surgical manipulations, the average count of double-labeled neurons at POD 60 was significantly less than at POD 21 (P < 0.05). CONCLUSION Autologous venous ensheathment could not help with the functional recovery of facial nerve or improve the accuracy of axonal regeneration. Further studies are warranted to elucidate the effects of venous ensheathment in other motor and sensory nerve models. LEVEL OF EVIDENCE NA. Laryngoscope, 127:1558-1564, 2017.

Aims The study was conducted to evaluate the incidence of urologic injuries during gynecologic surgery, study the management and outcome of such injuries, and identify risk factors that may be associated with urologic injuries. Methods A case–control study was conducted in patients who underwent gynecologic surgery from 2005 to 2014 in the university hospital. The study cases referred to patients who had urologic injury during gynecologic surgery and the control cases referred to patients who had gynecologic surgery matching the same period, type of procedure, and etiological disease leading to surgery. The medical records were reviewed and analyzed. Odds ratios (ORs) and 95% confidence intervals (CI) were used to identify risk factors associated with urologic injury. Results During the study period, there were 86 cases of urologic injuries from a total of 28 819 cases. The overall 10-year incidence was 0.30%. The incidence of bladder injury was 0.18%, (0.083% for ureteric and 0.014% for combined ureter and bladder injury). Among 80 cases with complete data, 52 (65%) had bladder injury and 48 (92.3%) were recognized the time of surgery and underwent primary repair with successful outcome, whereas 18 (75%) of 24 ureteric injury were detected intraoperatively. Previous pelvic surgery and the presence of adhesion were significant risk factors of urologic injury with OR 3.436, 95% CI 2.037–5.796 and OR 2.185, 95% CI 1.319–3.621, respectively. Conclusion Urinary bladder injury was the most common urinary tract injury during gynecologic surgery. Previous pelvic surgery and the presence of adhesion were significant risk factors.

Objectives The purpose of this study was to compare transvaginal 4-dimensional hysterosalpingo-contrast sonography with laparoscopic chromopertubation and evaluate the former's clinical value in assessing fallopian tubal patency and peritubal adhesion. Methods Fifty-six patients visiting infertility clinics were included in the study and underwent surgery by their own choice in 1 month. In total, 112 fallopian tubes were assessed. Twenty-five were primarily infertile, and the rest were secondarily infertile. Laparoscopic chromopertubation was taken as the reference standard. Results In a comparison of fallopian tubal patency between transvaginal hysterosalpingo-contrast sonography and laparoscopic chromopertubation, the sensitivity, specify, positive predictive value, and negative predictive value of hysterosalpingo-contrast sonography for diagnosing blocked fallopian tubes were 88.4%, 85.2%, 90.5%, and 82.1% respectively. In a comparison of spray at the fimbrial end between the no–peritubal adhesion and peritubal adhesion groups, the spray score at the fimbrial end in the no–peritubal adhesion group was significantly lower than that in the peritubal adhesion group. In a comparison of periovarian diffusion between the no–peritubal adhesion and peritubal adhesion groups, the periovarian diffusion score in the no–peritubal adhesion group was significantly lower than that in the peritubal adhesion group. In a comparison of periovarian diffusion between the patent-tube and blocked groups confirmed by chromopertubation, the periovarian diffusion score in the patent group was significantly lower than that in the blocked group. Conclusions Transvaginal hysterosalpingo-contrast sonography is a method with high sensitivity and specificity for screening fallopian tubal patency and peritubal adhesion.

OBJECTIVES To apply the three-dimensional (3D) hysterosalpingo-contrast sonography (HyCoSy) with perfluoropropane-albumin microspheres as contrast agents and normal saline injections into the pelvic cavity for assessment of the tubal patency and adhesions of fimbrial parts. METHODS Fifty-five infertile female patients were recruited to undergo 3D HyCoSy with normal saline injected into the pelvic cavity, in which the tubal patency was observed by visualizing the spillage of contrast agents from the fimbriae, and the fimbrial adhesion was confirmed by the finger-like projections of the fimbriae and their floating and moving status. RESULTS Of the 55 patients, bilateral tubal patency was observed in 44 (80.0%), unilateral tubal patency and the other partial occlusion in 7 (12.7%), unilateral partial occlusion and the other complete occlusion in 3 (5.4%), and bilateral complete occlusion in 1 (1.8%). The fimbrial parts were observed in 105 fallopian tubes, among which 101 were seen with the finger-like fimbriae floated and moved in the pelvic cavity, whereas 4 tubes were not because of adhesion to the pelvic cavity (n = 3) or the ovary and intestine (n = 1). More than three visible, quite long, and distributed evenly finger-like projections were present for the patent fimbrial parts; however, fewer, flat, and not evenly distributed finger-like projections were present for the adhesive tubes. No serious complications occurred during or after this procedure. CONCLUSIONS Combination of 3D HyCoSy with normal saline injected into the pelvic cavity may be a feasible and safe procedure to assess tubal patency and adhesions of the fimbrial parts.

Aim Postoperative pelvic adhesions are significant health care problems causing chronic pelvic pain, infertility and intestinal obstruction after abdominal or pelvic surgery. We investigated the effects of quercetin and Surgicel for the prevention of adhesions after gynecological surgery. Methods A double blind, randomized, controlled experimental study was designed. Forty female Wistar Hannover rats were divided into five groups: control, sham operated, quercetin, Surgicel, and quercetin + Surgicel. The control group received medication used for the surgical procedure only. The sham group received a laparotomy only. The quercetin group received 15 mg/kg quercetin in addition to undergoing the standard surgical procedure, and the injuries in the surgical group were covered with a single, 1 cm2 layer of Surgicel (oxidized regenerated cellulose). The quercetin + Surgicel group received both 15 mg/kg quercetin and a single, 1 cm2 layer of Surgicel. Adhesions were scored 14 days after the first surgical procedure. Results The extent, severity, degree, total adhesion, inflammation and fibrosis scores of the control group were significantly higher than those of the quercetin, Surgicel, and quercetin + Surgicel groups. There was no significant difference between the Surgicel and quercetin groups in degree, but all other parameters were significantly higher in the Surgicel than in the quercetin group. The quercetin + Surgicel group had lower adhesion scores than the quercetin group. Conclusions Quercetin, Surgicel and quercetin + Surgicel treatment may be useful for preventing pelvic adhesions.