Hydrodissection: an easy way to dissect anatomical planes and complex adhesions

Hydrodissection to create conjunctival flaps in dogs with corneal ulcers

Background and Aim

Hydrodissection is a liquid injection technique that is rarely used in animal ophthalmic procedures. The use of this technique in the creation of conjunctival flaps for the treatment of corneal ulcers in dogs can improve the outcome, task, and comfort for patients. This study aimed to evaluate the use of hydrodissection in the creation of conjunctival flaps in dogs with corneal ulcers.

Materials and Methods

This study focused on a surgical procedure for creating conjunctival flaps in the eyes of 17 dogs with deep corneal ulcers. We divided the patients into two groups: Hydrodissection was performed in the first group (G1) and conventional divulsion without hydrodissection in the second group (G2). In G1, the conjunctival flap was created by subconjunctival injection of 1 mL of 0.9% sodium chloride, followed by flap construction. The flap was constructed through conventional divulsion using iris scissors in the G2. The operative time, degree of bleeding, and ease of conjunctival divulsion were evaluated during the procedure. Blepharospasm, hyperemia, edema, and scarring of the conjunctiva were evaluated during the post-operative period. Post-operative complications, notably suture dehiscence, were recorded in each group.

Results

Hydrodissection is an easy-to-perform maneuver that optimizes the construction of conjunctival flaps. There were no statistical differences in the parameters used to evaluate the trans- and post-operative period between the groups. The volume of sodium chloride administered in the conjunctiva ranged from 0.5 mL to 1 mL in G1. Dehiscence of the flap sutures was observed in four patients (two in G1 and two in G2), with no significant difference between the groups.

Conclusion

Hydrodissection facilitates the construction of conjunctival flaps in dogs with corneal ulcers, affording greater comfort to patients and proving to be an excellent option for ophthalmologists.

Diagnostic Considerations in Compressive Neuropathies

Peripheral nerve compression of the upper extremity is a common pathology often necessitating surgical intervention, much is known, but much more is left to understand. For the more common pathologies, carpal tunnel syndrome, cubital tunnel syndrome, and ulnar tunnel syndrome, research and clinical efforts directed toward standardization and reduction of resource use have been attempted with varied success. Diagnosis of many of these syndromes is largely based on a proper history and physical examination. Electrodiagnostic studies continue to have value, but proportionally less than previous decades. In addition, emerging technologies, including magnetic resonance neurography, novel ultrasound evaluation techniques, and ultrasound-guided diagnostic injections, are beginning to demonstrate their ability to add value to the diagnostic algorithm, particularly when less common compressive neuropathies are present and/or the diagnosis is in question.

Case report: Injected corticosteroids for treating leprosy isolated neuritis

One of the main manifestations of leprosy is peripheral nerve impairment. Early diagnosis and treatment are important to reduce the impact of neurological impairment, which can cause deformities and physical disabilities. Leprosy neuropathy can be acute or chronic, and neural involvement can occur before, during, or after multidrug therapy, and especially during reactional episodes when neuritis occurs. Neuritis causes loss of function in the nerves and can be irreversible if left untreated. The recommended treatment is corticosteroids, usually through an oral regimen at an immunosuppressive dose. However, patients with clinical conditions that restrict corticosteroid use or that have focal neural involvement may benefit from the use of ultrasound-guided perineural injectable corticosteroids. In this study, we report two cases that demonstrate how the treatment and follow-up of patients with neuritis secondary to leprosy, using new techniques, can be provided in a more individualized way. Nerve conduction studies in association with neuromuscular ultrasound were used to monitor the response to treatment with injected steroids, focusing on neural inflammation. This study provides new perspectives and options for this profile of patients.

[Ultrasound-Guided Peritendinous Hydrodissection, an Alternative to Tenolysis Adhesions?]

Flexor tendon injuries of the hand treatment remains an important and common clinical problem. The rate of adhesions after flexor tendon tenorrhaphy is high. Today the treatment is surgical tenolysis, not always with satisfactory results. Ultrasound-guided hydrodissection is a novel interventional technique that consists of introducing a solution to free a compromised space or to distend and mechanically separate compressed or adhered structures. Ultrasound-guided hydrodissection is considered as an alternative to reoperation or after surgery failure. We report the first published case of ultrasound-guided peritendinous hydrodissection of adhesions after flexor tendon injury. We propose as an alternative to surgery or tenolysis, with encouraging results.

Case Report: Successful Outcome for Refractory Diabetic Peripheral Neuropathy in Patients With Ultrasound-Guided Injection Treatment

Diabetic peripheral neuropathy is the most prevalent chronic complication of diabetes and is based on sensory and autonomic nerve symptoms. Generally, intensive glucose control and nerve nourishment are the main treatments. However, it is difficult to improve the symptoms for some patients; such cases are defined as refractory diabetic peripheral neuropathy (RDPN). In this paper, we present five patients treated with saline and mecobalamin by ultrasound-guided injection. The Visual Analog Scale and Toronto Clinical Scoring System were used to evaluate the symptoms, and the neuro-ultrasound scoring system and electrophysiological severity scale were evaluated by ultrasound and electrophysiological examination. In brief, ultrasound-guided hydrodissection may be a safe way to treat RDPN.

Ultrasound-Guided Hydrodissection With Corticosteroid Injection in the Treatment of Carpal Tunnel Syndrome: A Pilot Study

OBJECTIVES

Corticosteroid injections can provide (temporary) relief in patients with mild to moderate carpal tunnel syndrome (CTS). Hydrodissection as part of an injection has been associated with positive clinical outcomes but data for CTS so far has been scarce. This study is designed to assess patient tolerance and secondarily provide pilot data on the added effect of hydrodissection.

METHODS

Twenty CTS patients were randomized to an ultrasound-guided betamethasone injection with hydrodissection (5 mL) or without (2 mL). Patient tolerance was assessed directly after intervention and patient-reported outcome after 4 and 24 weeks. Intra-group data were compared using Wilcoxon Signed Rank and inter-group with Wilcoxon rank-sum tests.

RESULTS

Tolerance and pain scores did not differ between the two groups. Symptom scores decreased in both groups, but to a lesser extent in the hydrodissection group with a mean difference of -0.8 versus -1.5 in the control group at 4 weeks (P = .02). At 6 months, this difference was no longer present (P = .81). No statistically significant differences were found between the hydrodissection and control groups in the function or pain scores at follow-up at either time point.

CONCLUSION

After injection, both symptomatic and functional scores improved, but the hydrodissected group did not show additional improvement. Data presented can be used to support larger studies to assess the value of hydrodissection in CTS management.

Hydrodissection as a therapeutic and diagnostic modality in treating peroneal nerve compression

A 51-year-old man presented with pain in the region of his left patellar tendon and fibular head. He had previously undergone three L5 epidural steroid injections and physical therapy without relief. Prior magnetic resonance imaging was significant only for fat pad impingement, and electromyography and nerve conduction studies were negative. Ultrasound demonstrated an enlarged peroneal nerve suggestive of peroneal nerve entrapment. Three ultrasound-guided hydrodissection procedures offered symptomatic improvement and identified an area posterior to the fibular head that was unable to be hydrodissected, indicating scar tissue causing peroneal nerve compression. The patient was referred for peroneal nerve decompression at the area of entrapment with complete symptom relief. This case is unique in describing the ability of hydrodissection to identify nerve compression not visualized with other diagnostic tests.

Targeted Ultrasound-Guided Perineural Hydrodissection of the Sciatic Nerve for the Treatment of Piriformis Syndrome

Piriformis syndrome is a common cause of lumbar, gluteal, and thigh pain, frequently associated with sciatic nerve symptoms. Potential etiologies include muscle injury or chronic muscle stretching associated with gait disturbances. There is a common pathological end pathway involving hypertrophy, spasm, contracture, inflammation, and scarring of the piriformis muscle, leading to impingement of the sciatic nerve. Ultrasound-guided piriformis injections are frequently used in the treatment of these pain syndromes, with most of the published literature describing injection of the muscle. We describe a safe, effective ultrasound-guided injection technique for the treatment of piriformis syndrome using targeted sciatic perineural hydrodissection followed by therapeutic corticosteroid injection.

Fascial Hydrodissection for Chronic Hamstring Injury

Hamstring muscle injuries (HMI) are common among athletes. HMI can take many months to years to resolve. Often, athletes do not report complete resolution with typical conservative therapy. We present several cases of athletes who presented with chronic hamstring injuries that resolved immediately after being treated with an ultrasound-guided fascial hydrodissection procedure. Following the procedure and graded rehabilitation protocol, athletes reported resolution of pain and tightness in addition to increased performance and a quicker return to play.

Preoperative Pneumoperitoneum: Low-Risk Surgical Adjunct to the Surgical Management of Dense Abdominal Adhesions

Surgical lysis of intra-abdominal adhesions is associated with a high rate of complications. This brief report presents 24 patients with dense intra-abdominal adhesions who underwent preoperative progressive pneumoperitoneum (PPP) prior to surgical lysis of adhesions. PPP was successfully performed in 23 patients, with few adverse events, resulting in subjectively improved ease of intraoperative tissue dissection. One patient withdrew due to intractable pain during insufflation. The results suggest that PPP is a low-risk technique with the potential to improve access to intra-abdominal structures in patients for whom conventional surgical therapy is predicted to carry a high rate of complications.

Clinical-anatomic mapping of the tarsal tunnel with regard to Baxter's neuropathy in recalcitrant heel pain syndrome: part I

Purpose

Neuropathy of the Baxter nerve (BN) seems to be the first cause of the heel pain syndrome (HPS) of neurological origin.

Methods

41 alcohol–glycerol embalmed feet were dissected. We documented the pattern of the branches of the tibial nerve (TN) and describe all relevant osteofibrous structures. Measurements for the TN branches were related to the Dellon–McKinnon malleolar-calcaneal line also called DM line (DML) for the proximal TT and the Heimkes Triangle for the distal TT. Additionally, we performed an ultrasound-guided injection procedure of the BN and provide an algorithm for clinical usage.

Results

The division of the TN was 16.4 mm proximal to the DML. The BN branches off 20 mm above the DML center or 30 mm distally to it. In most of the cases, the medial calcaneal branch (MCB) originated from the TN proximal to the bifurcation. Possible entrapment spots for the medial and lateral plantar nerve (MPN, LPN), the BN and the MCB are found within a circle of 5 mm radius with a probability of 80%, 83%, and 84%, respectively. In ten out of ten feet, the US-guided injection was precisely allocated around the BN.

Conclusions

Our detailed mapping of the TN branches and their osteofibrous tubes at the TT might be of importance for foot and ankle surgeons during minimally invasive procedures in HPS such as ultrasound-guided ankle and foot decompression surgery (UGAFDS).

Nerve Bundle Hydrodissection and Sexual Function after Robot Prostatectomy

Background and Objectives:

Loss of erectile function is common after prostatectomy, and surgeons have long sought techniques that reduce this adverse outcome. This study was conducted to assess erectile function after robot-assisted laparoscopic prostatectomy, with and without hydrodissection (HD) of the neurovascular bundles (NVBs).

Methods:

Using a database of 335 consecutive RALP procedures conducted by 2 surgeons, we identified all nerve-sparing surgeries performed by HD or standard dissection (SD). The primary and secondary endpoints were Sexual Health Inventory for Men (SHIM) scores and surgical margin positivity, respectively. Subset analyses were performed on men with preoperative SHIM scores ≥17. Determinants of the postoperative SHIM score were evaluated by multivariate linear regression.

Results:

Among men with preoperative SHIM scores ≥17 who underwent bilateral complete nerve sparing (n = 73), mean preoperative SHIM scores were similar in the HD and SD groups, but were significantly higher in the HD group at 6 months (16.1 ± 8.6 vs 8.3 ± 8.1; P = .024) and >1 year after surgery (16.9 ± 7.1 vs 9.1 ± 6.4; P = .004). According to multivariate linear regression analysis including all patients, HD at RALP (odds ratio [OR] 6.9; 95% confidence interval (CI) 2.8–11.0; P = .001) and preoperative SHIM score were independent predictors of erectile function at >1 year after surgery. There was no significant difference in surgical margin positivity between groups (P = .36).

Conclusion:

HD of the NVB appears to improve erectile function after RALP.

Role of Hydro-Dissection Facilitated Monopolar Cauterization Dissection Technique on Separation of the Greater Omentum From the Superior Layer of the Transverse Mesocolon During D2 Radical Gastrectomy

Adequate separation of the omentum from the transverse colon mesentery, during D2 radical gastrectomy, is usually difficult and often time-consuming due to anatomic variations. The aim of this prospective study was to compare the electrocautery dissection technique with hydrodissection-facilitated electrocauterization for the separation of the greater omentum from the superior layer of the transverse mesocolon in gastric cancer patients undergoing D2 radical gastrectomy. The time taken to separate the greater omentum from the superior layer of the transverse mesocolon, and the number and extension of iatrogenically-created mesocolonic defects were assessed. Forty patients were prospectively randomized into 2 groups. Separation of the greater omentum from the superior layer of the transverse mesocolon was achieved in Group I (n = 20) patients by the monopolar cauterization dissection technique whereas in Group II (n = 20) patients by the hydrodissection-facilitated monopolar cauterization. No significant difference was found between the 2 groups in terms of age, gender, body mass index (BMI), type of surgical technique, or the number of resected lymph nodes (P > 0.05). The difference between the 2 dissection techniques was not statistically significant when compared according to the number of iatrogenic mesocolonic defects, extension of the defects, or the time period required for the separation of greater omentum from the superior layer of the transverse mesocolon (P > 0.05). The overall survival was not significantly different between the 2 dissection techniques (P > 0.05). Hydrodissection is a safe technique that can be applied as an adjunct to electrocauterization to facilitate the dissection in the correct plane during resection of the mesogastrium.

Percutaneous Ultrasound-Guided Hydrodissection of a Symptomatic Sural Neuroma

Symptomatic neuromas of the sural nerve are a rare but significant cause of pain and debilitation in athletes. Presentation is usually in the form of chronic pain and dysesthesias or paresthesias of the lateral foot and ankle. Treatment traditionally ranges from conservative measures, such as removing all external compressive forces, to administration of nonsteroidal anti-inflammatory drugs, vitamin B6, tricyclic antidepressants, antiepileptics, or topical anesthetics. This article reports a case of sural nerve entrapment in a 34-year-old male triathlete with a history of recurrent training-induced right-sided gastrocnemius strains. The patient presented with numbness in the right lateral foot and ankle that had persisted for 3 months, after he was treated unsuccessfully with extensive nonoperative measures, including anti-inflammatory drugs, activity modification, and a dedicated physical therapy program of stretching and strengthening. Orthopedic assessment showed worsening pain with forced passive dorsiflexion and manual pressure applied over the distal aspect of the gastrocnemius. Plain radiographs showed normal findings, but in-office ultrasound imaging showed evidence of sural nerve entrapment with edema and neuromatous scar formation in the absence of gastrocnemius or soleus pathology. Percutaneous ultrasound-guided hydrodissection of the sural nerve at the area of symptomatic neuroma and neural edema was performed the same day. The patient had complete relief of symptoms and full return to the preinjury level of participation in competitive sports. This case report shows that hydrodissection, when performed by an experienced physician, can be an effective, minimally invasive technique for neurolysis in the setting of sural nerve entrapment, resulting in improvement in clinical symptoms.

Skinning clitorectomy and skin replacement in women with vulvar intra-epithelial neoplasia

BACKGROUND AND AIM

Partial or total clitoris amputation for vulvar intra-epithelial neoplasia (VIN) affects quality of life and sexual function and is likely to constitute over-treatment as superficial excision of only the involved, thinly cornified, stratified squamous clitoral epithelium would suffice. For this reason, we applied skinning clitorectomy and replacement of clitoral skin as an organ-sparing surgical therapy for clitoral VIN.

METHODS

Seven consecutive patients presenting with VIN were treated from July 2003 to February 2008. The skin of the glans clitoridis was resected from the underlying spongious tissue by combined hydro-dissection and sharp dissection. The spongiosum was subsequently covered with either a thin skin flap from the inner aspect of the remaining preputium or minor labium, or a split-thickness skin graft taken from the proximal inner aspect of the thigh.

RESULTS

In all patients, the preoperative diagnosis of VIN was confirmed histopathologically. Additionally, micro-invasive carcinoma was found in two. The postoperative course was complicated by haematoma in one patient and a superficial infection in another, but these did not influence the overall satisfactory outcome obtained in all patients. Preoperative sexual function was largely preserved and, after a mean follow-up of 21 months, no recurrence or invasion of the original lesion was observed in any of the patients.

CONCLUSION

We advocate skinning clitorectomy and replacement of its skin as a sound organ-sparing alternative for clitoral amputation in the treatment of clitoral VIN.

Systematic guide to complex cases from adhesive disease

Intestinal adhesions are inevitable after abdominal surgery. The presence of intra-abdominal adhesions can create very complex situations which require careful preoperative planning, meticulous intra-operative technique and detailed postoperative management. This manuscript will review the management of these complex cases of adhesions.

Hydrodissection with adrenaline–lidocaine–saline solution in laparoscopic cholecystectomy

AIM

This investigation examined the effects of a solution injected to the gallbladder bed on operative time, bleeding, incidence of gallbladder perforation, and postoperative pain.

METHODS

One hundred sixty-four consecutive patients with cholelithiasis were randomized into two clinically comparable groups. In group 1 (84 patients), 40 ml of saline-adrenaline-lidocaine solution was injected between the gallbladder and liver. In group 2 (80 patients), laparoscopic cholecystectomy was performed without hydrodissection. The time taken to dissect the gallbladder from the liver, bleeding from the liver bed, incidence of gallbladder perforation and spillage of bile and stones, duration of operation, amount of gas used for the laparoscopic cholecystectomy, conversion to open cholecystectomy, postoperative pain and pain localization were recorded.

RESULTS

The mean dissection time, amount of gas used, incidence of gallbladder perforation, spillage of stones, and liver bed bleeding were not significantly different between the groups. There also was no significant difference between the groups regarding postoperative pain and pain localization.

CONCLUSION

Hydrodissection did not reduce time to dissect the gallbladder from the liver or risk of gallbladder perforation. Similarly, adrenaline and lidocaine injection between the gallbladder and the liver did not effect bleeding from the dissection area and did not alter postoperative pain or pain localization.

Kidney transplantation in the rat: A modified technique using hydrodissection

Here, hydrodissection was compared with the conventional blunt instrumental dissection approach in a rat model of orthotopic kidney transplantation. Forty male Fisher and Lewis rats were used as kidney donors and recipients, respectively. After recipient nephrectomy, left kidney grafts were implanted orthotopically using standard microsurgical techniques. Two different methods of dissection of the graft and recipient vessels were used. In method A, the dissection was performed using blunt dissection with cotton-tipped sticks and jeweler's forceps (n = 20), and in method B, dissection was performed using water dissection technique (n = 20). Hydrodissection displayed the correct plane of dissection, reduced the operating time, and reduced the overall complication (P < 0.001) and vasospasm (P < 0.05) rates. This is the first report of the use of hydrodissection in experimental transplantation. This atraumatic dissection technique does not require any special instruments, is fast, safe, demands less surgical skills, and may be useful in other transplantation models.

Hydro-Jet-assisted laparoscopic cholecystectomy: a prospective randomized clinical study

BACKGROUND

A new dissection technique with high-pressure water stream (Hydro-Jet) has recently been applied for selective dissection during various surgical procedures. The aim of this study was to compare Hydro-Jet with the conventional technique for laparoscopic cholecystectomy.

METHODS

Eighty patients were randomized to undergo laparoscopic cholecystectomy with standard (n = 40) or Hydro-Jet-assisted (n = 40) dissection techniques. The rates of intraoperative complications, including blood loss and injury to the adjacent organs, were compared between the groups. The versatility of this technique and the features of surgical dissection were also evaluated and compared.

RESULTS

Laparoscopic cholecystectomy was successfully completed in all subjects. The mean operative times were 78 minutes (range, 52-120 minutes) and 81 minutes (range, 45-135 minutes) for Hydro-Jet versus conventional dissection, respectively (P = not significant). Complications included gallbladder perforation in 15% and 30% (P <.1) and liver laceration in 0% and 10% (P <.04) with Hydro-Jet and conventional techniques, respectively. Increased hemorrhage from the gallbladder bed that necessitated fulguration occurred in 12 patients with the conventional technique as compared with none in the Hydro-Jet group (P <.001). Hydro-Jet resulted in a selective dissection of connective tissue preserving blood vessels and the cystic duct. The continuous water flow allowed a clear view for the operator, and the dissection was performed in a relatively bloodless field. The ease of blunt dissection with the bent-tip dissector represents another advantage.

CONCLUSION

This study shows that Hydro-Jet dissection represents an excellent alternative to the conventional technique for laparoscopic cholecystectomy. The improved anatomic dissection combined with an almost bloodless operating field as the result of continuous water flow decreased the rate of dissection-related complications.

Hydro-jet-assisted pneumonectomy: a new technique in a porcine model

BACKGROUND AND OBJECTIVES

Hydro-jet technology has long been used to cut various materials, such as metal and wood, in the industrial field. In the medical field, this technology has been applied successfully in selective cutting of the parenchyma of the liver. However, to our knowledge, no data are available on the use of the hydro-jet technique for pneumonectomy. The purpose of this study was to evaluate a new dissection technique in which a high-pressure water stream (hydro-jet) and a new dissection probe for pulmonary resection are used.

METHODS

Thirty pigs underwent right pneumonectomy. Pigs were randomized to either the conventional or hydro-jet-assisted dissection technique. The feasibility of this technique and the features of surgical dissection were evaluated and compared between the two groups.

RESULTS

Pneumonectomy was successful in all animals. The mean operative times were 55 and 65 minutes and the mean volumes of blood loss were 37 and 65 mL for the hydro-jet and conventional dissection techniques, respectively. Complications included vascular injury in 6% and 20% of cases with the hydro-jet and conventional techniques, respectively. The use of hydro-jet for pneumonectomy had clear technical advantages over the conventional dissection. Hydro-jet resulted in a selective dissection of fibrous and connective tissue, preserving blood vessels for later ligation. Therefore, the dissection was performed in a relatively bloodless field. The ease of dissection with the bent-tip dissector represents another advantage. The continuous water flow allows a clear view for the operator.

CONCLUSIONS

This study shows that hydro-jet dissection represents an excellent alternative to the conventional technique for pulmonary resection. The improved anatomic dissection combined with an almost bloodless operating field secondary to continuous water flow may decrease dissection-related complications.

Hydro-jet dissection for laparoscopic nephrectomy: a new technique

OBJECTIVES

The Hydro-Jet technique has been used to cut various industrial materials. In the medical field, this technique has been successfully used for selective dissection of the parenchyma of organs such as the liver. Recently, this technique was successfully used for laparoscopic cholecystectomy in humans. We developed a new Hydro-Jet probe and a technique of Hydro-Jet dissection during laparoscopic nephrectomy (LN) in a porcine model and compared the results with those of conventional laparoscopy.

METHODS

Fourteen pigs underwent unilateral LN using the Hydro-Jet and a conventional LN on the contralateral side. A Muritz 1000 Hydro-Jet generator was used. An adjustable water pressure gauge allowed manual control up to a maximum of 30 atm, and coagulation was applied by way of a bipolar thermoapplicator. The bent end of the probe allowed both blunt dissection and concomitant high-pressure water application. Results were compared with regard to ease of anatomic dissection, complications, and operative time between the two techniques.

RESULTS

LN was successful in all animals with no conversion to open surgery. The dissector allowed anatomic planes to be created in a relatively bloodless field, and continuous water flow allowed a clear view for the operator. The high-pressure stream resulted in excellent dissection of adventitial and soft tissue adjacent to vascular structures, with complete preservation of vessels and ureter for selective ligation. The dissection time was shortened (mean 27 minutes for the Hydro-Jet versus 40 minutes for the conventional technique).

CONCLUSIONS

To our knowledge, we describe the first report of Hydro-Jet dissection for LN as an alternative to the conventional technique. The improved anatomic dissection may decrease complications. Moreover, shorter operating times were achieved, which may result in cost savings. Further studies in humans are necessary to investigate this technique.