Fimbriectomy is a very uncommon type of tubal ligation that is performed by removing the end (fimbria) of the fallopian tube leaving only the tubal segment attached to the uterus. After fimbriectomy, if the remaining tubal segment is long enough, the end of the tube can be opened and 'new' fimbria can be created by a procedure called a neofimbrioplasty. These "new" fimbria are not actually fimbria, but they are the cilia from the inside of the fallopian tube that have been exposed by everting the tubal lumen much like the petals of a rose are exposed once the rose blooms. These 'new' fimbria are much less effective at collecting (catching) an egg that has been released from the ovary than the real fimbria that had been removed during the fimbriectomy performed by the surgeon who did the original tubal ligation. During a neofimbrioplasty the tubal end is opened and folded back ( marsupialized ) so that the tubal end remains open and exposing the internal lining of the tube.


Mini-laparotomy for tubal reversal surgery involves making a small, 2 to 3 inch incision in the abdominal wall just above the pubic bone after shaving the hair with a sterile hair clipper. The size and location of the incision as well as the plastic surgery techniques used to close it make the thin scar nearly invisible after it has healed. Atraumatic surgical techniques involve the use of local anesthesia at the incision site and other tissues operated upon. This makes the surgery comfortable and minimizes post-operative pain. As opposed to standard operative methods, avoiding  the use of surgical retractors and packs, constantly irrigating tissues to keep them moist and at body temperature, and operating under magnification throughout the procedure results in very rapid patient recovery.  Operating with microsurgical instruments allows precision in  suturing of the tubal segments.


In this Process, The area of the tubes which was occluded is removed, leaving only open, healthy tube. These open, healthy, tubal segments are then connected. A multi layer, micro surgical technique is used to suture these segments together. After the tubes are repaired, a  chromopertubation  is performed wherein dye is injected into the uterus. This dye is passed through the repaired tubes to ensure that the tubes are open. The entire surgery is performed through a small incision of about 3 to 4 inches just at the uppermost part of the hair line. Failing to properly align the tubal segments, or damaging these delicate structures, can make the difference between a successful and an unsuccessful operation. [ 3 ]


Laparoscopic Tubal Reversal is a minimally-invasive surgical procedure ( laparoscopy ), using small, specially-designed instruments to repair and reconnect the fallopian tubes.


After general anesthesia has been administered, a 5mm (less than 3/8-inch) tube ( trocar ) is inserted inside the navel, and a special gas is pumped into the abdomen to create enough space to perform the operation safely and precisely. The  laparoscope  (a telescope), attached to a camera, is brought into the abdomen through the same tube, and the pelvis and abdomen are thoroughly inspected. The fallopian tubes are evaluated and the obstruction (ligation, burn, ring, or clip) is examined. Three small instruments (5mm each, less than  1 ⁄ 4 -inch) are used to remove the occlusion and prepare the two segments of the tube to be reconnected.


Once the connection ( anastomosis ) is completed, a blue dye is injected through the cervix, traveling through the uterus and tubes, all the way to the abdomen. This is to make sure the tubes have been aligned properly and that the connection is working well.


Patients are sent home the same day of surgery. The few stitches that are placed will be under the skin and will be absorbed by the body, without need for removal.


Patients should wait two months prior to attempting pregnancy in order to give the tubes a chance to heal completely. Trying to conceive before could result in an increased risk of  ectopic pregnancy  (pregnancy inside the fallopian tube instead of in the uterus).


When performed by a trained laparoscopic tubal reversal surgeon, laparoscopic tubal reversal combines the success rates of micro-surgical techniques with the advantages of minimally-invasive surgery – namely faster recovery, better healing, less pain, fewer complications, and no large disfiguring scars. [ 4 ]  Laparoscopic surgery can be more expensive than an open surgery using a 2 to 3 inch incision because it requires additional surgical equipment.


Robotic assisted tubal reversal surgery is a surgical procedure in which the fallopian tubes are repaired by a surgeon using a remotely controlled, robotic surgical system.


The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon's console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon's console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon's console.


Robotic tubal ligation reversal uses the same small incisions as a traditional laparotomy tubal reversal surgery. Smaller incisions generally result in less pain and quicker return to work when compared to traditional tubal ligation reversal using larger abdominal incisions. The robotic system offers a greater range of motion and more surgical dexterity than a surgeon can obtain during laparoscopic tubal ligation reversal, but not as much dexterity as with an open procedure using a 2 to 3 inch incision. The disadvantages to robotic surgery are longer operating times and much higher costs than even traditional laparoscopic surgery.


A retrospective, Cleveland Clinic study compared 26 patients who underwent robotic assisted tubal reversal to 41 patients who underwent outpatient mini-laparotomy (abdominal incision) tubal reversal.  Robotic tubal reversal patients, when compared to abdominal tubal reversal surgery patients, had longer times under anesthesia (283 minutes vs 205 minutes) and longer times in surgery (229 minutes vs 181 minutes). On average, robotic tubal reversal patients returned to work one week sooner than abdominal tubal reversal patients and the robotic tubal reversal surgeries were also more expensive than abdominal tubal reversal surgeries. [ 5 ]


An Ohio State University study evaluating robotic tubal reversal vs abdominal tubal reversal discovered similar findings but also evaluated pregnancy outcomes. Robotic tubal reversal surgery, when compared to abdominal tubal reversal surgery, had longer operative times (201 minutes vs 155 minutes), shorter hospital stays (4 hours compared to 34 hours), and quicker return to activities of daily living. Pregnancy outcomes of robotic tubal reversal surgery patients were also compared to pregnancy outcome of abdominal incision tubal reversal patients. Approximately 65% of the robotic tubal reversal surgery patients became pregnant compared with 50% of the abdominal incision patients. Of the pregnancies, 6 abnormal pregnancies were in the robotic tubal reversal patients (4 ectopic and 2 miscarriage) and 2 were in the abdominal incision patients (1 ectopic and 1 miscarriage). Both surgeries were expensive and were found to cost in excess of $92,000. Robotic tubal reversal surgery was slightly more costly than the abdominal incision tubal reversal. [ 6 ]


Essure sterilization  was a tubal occlusion procedure that was approved by the FDA in 2002. The Essure procedure involves inserting a small camera ( hysteroscope ) through the  cervix  and into the uterine cavity. Two small, metallic coils are then inserted into each tubal  ostia  and into the isthmic portion of the fallopian tube. The coils cause the isthmic portion of the fallopian tube to be blocked with scar tissue. To confirm tubal closure, a  hysterosalpingogram  should be performed three months after the Essure procedure. If either fallopian tube is open after the Essure procedure, then the Essure procedure can be repeated or another type of tubal occlusion method can be performed. Essure was discontinued in 2018 due to a large number of reported  serious adverse events . [ 7 ]


Reversal of Essure sterilization requires the blocked isthmic portion of the tube be bypassed by tubouterine implantation. During a tubouterine implantation procedure, the blocked portion of the fallopian tube containing the Essure sterilization device is surgically resected. The remaining portion of each healthy fallopian tube is then reintroduced into the newly created openings. This procedure can restore the natural function of the fallopian tube and allow for natural conception. The first case of successful outpatient tubouterine implantation to reverse Essure sterilization was published in 2012. [ 8 ]


Surgeons who published the first case report of successful Essure reversal subsequently published a larger cohort study of 70 patients who underwent outpatient tubouterine implantation to reverse Essure sterilization and 36% of patients reported pregnancy through natural conception. [ 8 ]


Dr. Charles Monteith, Medical Director of A Personal Choice Tubal Reversal Center, has collected non-published data on the risks of outpatient Essure reversal surgery. [ citation needed ]  Between 2009 and 2018, Monteith performed 469 outpatient tubouterine implantation procedures to reverse Essure sterilization. He documented intraoperative, postoperative, and pregnancy risks associated with his procedures.


Intraoperative risks observed were failure to complete the planned procedure (either Essure removal and tubal occlusion or Essure removal and bilateral tubouterine implantation) <1%, fracture of Essure devices during removal (approximately 10% risk with manual traction and < 1% with en bloc dissection), transfer to hospital <1%, referral to Emergency room or hospital within 24 hours of surgery <1%, bleeding requiring blood transfusion or hospitalization for operative complication 0%, anesthesia complication 0%, and death 0%.


Postoperative risks observed were major surgical site infection 0%, minor surgical site infection <1%, need for a second operation/procedure within 30 days <1%, and persistent symptoms requiring additional surgery < 10%.


Pregnancy related risks were failure to become pregnant and possible tubal closure (estimated to be <60%) and ectopic pregnancy 5%.
All patients were advised to have a planned cesarean delivery before the onset of labor and the risk of uterine rupture was observed to be 4%. The majority of uterine ruptures occurred at 36/37 weeks gestation.


Factors associated with more difficult surgical procedures were patient obesity (BMI ≥ 30), presence of uterine leiomyomas, and uterine adhesive disease primarily from prior cesarean delivery. [ 9 ]


Adiana sterilization was approved by the FDA in 2009. Adiana sterilization is a hysteroscopic tubal occlusion procedure, which is very similar to  Essure  sterilization. The Adiana procedure involves inserting a small camera (hysteroscope) through the cervix and into the uterine cavity. A smaller catheter is inserted into the tubal ostia. The catheter emits radiowaves (microwaves). The radiowaves cause injury to the tubal lining and will result in the tube gradually closing. Prior to removal of the catheter a small silicone stent is left inside the isthmic portion of the tube and this promotes tubal closure by the acceleration of the tubal scarring.


Adiana sterilization is similar to Essure sterilization and the Adiana procedure causes blockage of the proximal isthmic portion. Adiana sterilization can surgical reversed with tubouterine implantation. The first case of successful outpatient tubouterine implantation to reverse Adiana sterilization was published in 2011. [ 10 ]


Hologic Corporation discontinued the procedure in March 2012, resolving ongoing litigation with Conceptus concerning patent infringement claims. [ 11 ]


Tubal reversal success rates vary widely depending upon many factors. [ 12 ]  These include the women's ages, methods of tubal ligation that they had performed, experience of the surgeon and techniques for repairing the tubes, length of follow-up after reversal surgery among other factors. Overall, for those who are less than 35 years of age at the time of reversal, more than 70% achieve intrauterine pregnancy, with most pregnancies occurring within 18 months after surgery. [ 12 ]  Overall, for those who are 35 years of age or more, approximately 55% will achieve an intrauterine pregnancy. [ 12 ]


Tuboplasty  refers to a number of surgical operations that attempt to restore patency and functioning of the  fallopian tube (s) so that a pregnancy could be achieved. As tubal infertility is a common cause of  infertility , tuboplasties were commonly performed prior to the development of effective  in vitro fertilization  (IVF) or repair of any type of tube-like structure, including the  Eustachian tube  in the head and neck. [ citation needed ]


Different types of tuboplasty can be distinguished: [ 1 ] [ 2 ]


Above surgical procedures are performed through either a  laparotomy  or  laparoscopy  approach.
Techniques include the use of  microsurgery ,  laser ,  electrocautery ,  hydrodissection , mechanical  dissection , and use of surgical  stents , hoods, adhesions barriers, and more. [ citation needed ]


Results depend on the underlying pathology and the skill of the surgeon.  Pregnancy rates  may range from 0–48% (Rock, 1985). [ 3 ]


Ectopic pregnancy  is a complication  after a tuboplasty. It may require a  salpingectomy  (removal of a tube).


Schroder is credited to have performed the first tuboplasty when he created an ampullary cuff and thus reopened an occluded tube in 1884. [ 2 ]  The first postoperative pregnancy was reported by Martin in 1891, however it aborted. For about a century tuboplastic procedures were the main approach to correct tubal infertility situations. With the development of IVF technology, IVF has increasingly supplanted tuboplasty as a treatment for tubal infertility. [ citation needed ]


Myomectomy , sometimes also called  fibroidectomy , refers to the surgical removal of  uterine leiomyomas , also known as fibroids. In contrast to a  hysterectomy , the  uterus  remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle. [ 1 ]


The presence of a fibroid does not mean that it needs to be removed. Removal is necessary when the fibroid causes pain or pressure, abnormal bleeding, or interferes with reproduction.  The fibroids needed to be removed are typically large in size, or growing at certain locations such as bulging into the endometrial cavity causing significant cavity distortion.


Treatment options for uterine fibroids include observation or medical therapy, such a  GnRH agonist ,  hysterectomy ,  uterine artery embolization , and  high-intensity focused ultrasound  ablation.


A myomectomy can be performed in a number of ways, depending on the location, size and number of lesions and the experience and preference of the surgeon. Either a general or a spinal anesthesia is administered.


Traditionally a myomectomy is performed via a  laparotomy  with a full abdominal incision, either vertically or horizontally. Once the peritoneal cavity is opened, the uterus is incised, and the lesion(s) removed. The open approach is often preferred for larger lesions. One or more incisions may be set into the uterine muscle and are repaired once the fibroid has been removed. Recovery after surgery takes six to eight weeks.


Using the  laparoscopic approach  the uterus is visualized and its fibroids located and removed.
Studies have suggested that laparoscopic myomectomy leads to lower  morbidity  rates and faster recovery than does laparotomic myomectomy. [ 2 ]  As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids.  A study of laparoscopic myomectomies conducted between January 1990 and October 1998 examined 106 cases of laparoscopic myomectomy, in which the fibroids were intramural or subserous and ranged in size from 3 to 10 cm. [ 3 ]


A fibroid that is located in a submucous position (that is, protruding into the endometrial cavity) may be accessible to  hysteroscopic  removal. This may apply primarily to smaller lesions as pointed out by a large study that collected results from 235 patients with submucous myomas who were treated with hysteroscopic myomectomies; in none of these cases was the fibroid greater than 5 cm. [ 4 ]  However, larger lesions have also been treated by hysteroscopy. [ 5 ]  Recovery after hysteroscopic surgery is but a few days.


Complications of the surgery include the possibility of significant blood loss leading to a  blood transfusion , the risk of  adhesion  or scar formation around the uterus or within its cavity, and the possible need later to deliver via  cesarean section . [ 6 ]


It may not be possible to remove all lesions, nor will the operation prevent new lesions from growing. Development of new fibroids will be seen in 42–55% of patients undergoing a myomectomy. [ 7 ]


It is well known that myomectomy surgery is associated with a higher risk of  uterine rupture  in later pregnancy. [ 8 ]  Thus, women who have had myomectomy (with the exception of small submucosal myoma removal via hysteroscopy, or largely pedunculated myoma removal) should get  Cesarean  delivery to avoid the risk of uterine rupture that is commonly fatal to the fetus.


To reduce bleeding during myomectomy, the use of  misoprostol  in the vagina and the injection of  vasopressin  into the uterine muscle are both effective. [ 9 ]  There is less evidence supporting the usefulness chemical dissection (such as with  mesna ), vaginal insertion of  dinoprostone , a  gelatin – thrombin  matrix,  tranexamic acid , infusion of  vitamin C , infiltration of a mixture of  bupivacaine  and  epinephrine  into the uterine muscles, or the use of a  fibrin  sealant patch. [ 9 ]


Leiomyomata tend to grow during pregnancy but only the large ones causing endometrial cavity distortion could interfere with the growing pregnancy directly. [ 10 ]  Generally, surgeons tend to stay away from operative interventions during the pregnancy because of the risk of haemorrhage and the concern that the pregnancy may be interrupted. Also, after a pregnancy, myomas tend to shrink naturally. However, in selected cases myomectomy may become necessary during pregnancy, or also at the time of a  caesarean section  to gain access to the baby. [ 11 ]


For removing uterine fibroids, myomectomy and uterine artery embolisation seem to be equally effective in improving  quality of life , as measured 4-yours after surgery. [ 12 ] [ 13 ]


Vaginal evisceration  is an  evisceration  of the  small intestine  that occurs through the  vagina , typically subsequent to  vaginal hysterectomy , and following  sexual intercourse  after the surgery. It is a  surgical emergency . [ 1 ]


Vaginal evisceration is typically obvious upon presentation, as intestine (typically  ileum ) can be seen protruding from the  introitus . Other symptoms include a sense of pressure in the pelvis and  vaginal bleeding . [ 1 ]


Complications of surgery can include injury to the  bladder ,  rectum , or  ureter , especially in cases where there has been tissue  necrosis . Surgeons typically perform intraoperative  cystoscopy  with dye to assess potential bladder or ureter injuries. [ 1 ]


Vaginal evisceration is a serious complication of  dehiscence  (where a surgical wound reopens after the procedure), which can be due to trauma. [ 1 ]  63% of reported cases of vaginal evisceration follow a  vaginal hysterectomy  (where the uterus removal surgery is performed entirely through the vaginal canal). [ 2 ]  Most instances of vaginal evisceration following a laparoscopic hysterectomy result from sexual intercourse among women approaching  menopause , and from the combination of heightened pressure within the abdomen and weakened vaginal muscles among those who have experienced menopause. [ 3 ] [ 4 ]  Other risk factors include regular  Valsalva maneuver , advanced age,  obesity ,  smoking ,  immunosuppressive therapy ,  vaginoplasty ,  anemia , poor surgical technique,  malnutrition , and postoperative/perioperative infection. [ 5 ] [ 6 ]  One case has been reported as of 2015 where placement of a  pessary  caused an evisceration. [ 5 ] [ 7 ]


Dehiscence is more common in laparoscopic hysterectomy than in open hysterectomy. [ 8 ]


When performing a vaginal hysterectomy, surgeons should aim to avoid damaging surrounding tissue or drying the vaginal cuff. Surgeons should take extra care to align the tissues, and include sufficient undamaged tissue. Instead of  single-layer figure-of-eight sutures , two-layer sutures can aid in preventing vaginal evisceration. [ 3 ]


Emergently, vaginal eviscerations are treated by keeping the exposed intestines moist and wrapped, while waiting for definitive surgical treatment. [ 1 ]  Vaginal evisceration is usually treated by  removing damaged tissue  along the edges of the  vaginal cuff , re-suturing the opening, and giving the patient broad-spectrum  antibiotic prophylaxis . [ 3 ]


Surgery can be conducted via a  laparotomy , though research from the 2010s shows that a transvaginal or laparoscopic approach can also be used safely and successfully if an infection has not developed. If left untreated, it can cause  peritonitis  or injury to the exposed bowel, including  strangulation  or  mesenteric tears .  Cellulitis ,  abscesses ,  hematomas , and other complications can appear at the same time as an evisceration. Abscesses and hematomas can be resolved after surgery with a  surgical drain . [ 1 ]


Post-surgical treatment includes continuation of antibiotics and, in some  postmenopausal  people, vaginal estrogen to speed recovery. After surgery, people with vaginal evisceration are advised to avoid intercourse until the surgical site is fully healed. [ 1 ]


Though it is a rare complication, as the popularity of laparoscopic hysterectomy has risen, the rate of vaginal evisceration has also risen. Vaginal cuff dehiscence occurs in 0.24–0.39% of cases; of these, vaginal evisceration occurs in 35%–67%. [ 1 ]  When all surgical procedures are considered, the rate of vaginal evisceration is 0.032–1.2%. [ 2 ]


The first report of vaginal evisceration in the medical literature was published in 1864 by Belgian obstetrician Léon Hyernaux; it occurred secondary to traumatic rupture of the vagina during an unsuccessful attempt at  forceps delivery . The patient, a 42-year-old woman, survived and made a complete recovery. [ 6 ] [ 9 ]


Vaginectomy  is a surgery to remove all or part of the  vagina . It is one form of treatment for individuals with  vaginal cancer  or  rectal cancer  that is used to remove tissue with cancerous cells. [ 1 ]  It can also be used in  gender-affirming surgery . Some people born with a vagina who  identify  as  trans men  or as  nonbinary  may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like ( metoidioplasty ), construct of a full-size penis ( phalloplasty ), or create a relatively smooth, featureless genital area ( genital nullification ). [ 2 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ]


If the  uterus  and  ovaries  are to remain intact, vaginectomy will leave a canal and opening suitable for draining  menstrual discharge . Otherwise, as in genital nullification, a  hysterectomy  must be performed to avoid the danger of retaining menstrual discharge within the body. [ 7 ]  In the latter case, thorough removal of vaginal lining is necessary to avoid continued secretion within the body. [ 8 ]


In addition to vaginectomy in humans, there have been instances of vaginectomy in other animals to treat vaginal cancer. [ 9 ]


Total or partial vaginectomy along with other procedures like laser vaporization can be used in the treatment of  vaginal intraepithelial neoplasia . These procedures remove the cancerous tissue and provide tissue samples to help identify underlying/invasive cancer while maintaining structure and function of the vagina. This surgery along with radiation therapy used to be the optimal treatment for high-grade vaginal intraepithelial neoplasia. However, high rates of recurrence and severe side effects such as vaginal shortening, bleeding and sepsis have narrowed its uses. A partial upper vaginectomy is still the treatment of choice for certain cases of vaginal intraepithelial neoplasia as it has success rates ranging from 69 to 88%. [ 10 ]


A vaginectomy is often necessary to remove all cancerous tissue associated with  rectal cancer . Depending on the extent of rectal cancer, a total or partial vaginectomy may be indicated to improve long-term survival. Following the surgery and removal of rectal tumors, vaginal and rectal reconstructive surgery can improve healing and may help with self-image and sexual function. [ 11 ]


Although there has not been a consensus on the standard treatment for penis construction in transgender men, a vaginectomy is a vital step in many of the various techniques. Depending on the reconstructive surgeon and which method is used, the basic outline of the procedure involves taking skin from an area of the body like the forearm or abdomen followed by glans sculpture, vaginectomy, urethral anastomosis,  scrotoplasty  and finished with a  penile prosthesis  implantation. The ideal outcome of this procedure, as described by the  World Professional Association for Transgender Health  (WPATH), is to provide an aesthetically appealing penis that enables sexual intercourse and sensitivity. Complications do arise from this procedure which may include tissue death, urethral complications, and infection. [ 12 ]


Radial Forearm Free Flap (RAFFF) is one of the techniques considered for  total phallic construction . [ 12 ]  Developed and performed in 1984, RAFFF consists of three stages and a complete vaginectomy is the second stage of RAFFF. The preferred technique is ablation vaginectomy with simultaneous scrotoplasty, which will close the  labia majora  along the midline. [ 13 ]


An anterior pelvic exenteration with total vaginectomy (AETV) is a procedure that removes the  urinary system  (kidneys, ureters, bladder, urethra) as well as the gynecologic system ( ovaries ,  fallopian tubes ,  uterus ,  cervix ,  vagina ) and is used as treatment of recurrent gynecologic cancers. A total  pelvic exenteration  can also be used as treatment which involves the removal of the  rectum  in addition to the urinary and gynecologic systems. The decision between the two procedures depends on extent of the cancer. Potential benefits of an AETV over a total pelvic exenteration include reduced risk of intestinal injury. [ 14 ]


Neovaginectomy has been performed to remove the  neovagina  following  vaginoplasty , for instance in  transgender women  who experience neovaginal complications or those who choose to  detransition . [ 15 ]


The safety of vaginectomy can depend on individual medical conditions and the subsequent risks they pose. For example, for people with  diabetes  mellitus, potential contraindications for vaginectomy include wound-healing difficulty; for people who prefer to not undergo  hormone therapy , potential contraindications include gonad removal ( oophorectomy  or  orchiectomy ). [ 16 ]


Many people who undergo vaginectomy do so for sexual health and intimacy. However, risks of vaginectomy include post-operative sensory issues that range from lack of sensation to excessive sensation, such as  hypersensitivity  or even  pain . [ 16 ]  To address this, skin grafting is often done with vaginectomy to allow recovery of sexual function. [ 17 ]


Other risks may involve consequences of the procedure itself. For example, possible injuries include  rectal  injury (due to the proximity of the structures), development of a  fistula  (an abnormal connection between two body parts), or, for people who have phalloplasty done in conjunction with vaginectomy, irritation or even erosion of the skin of the  phallus . Some of these locations may be suture sites; irritation of these sites may increase likelihood of infection. [ 18 ]


There are pre- and post-operative steps that can be taken to minimize complications from vaginectomy. For example, other procedures that are often performed in conjunction with vaginectomy, such as metoidioplasty and phallourethroplasty, can be performed in two stages to increase the likelihood of a favorable cosmetic outcome. [ 19 ]  Also, waiting for a period of time after completing a procedure, usually a minimum of 4 months, ensures that the person undergoing the surgery is clear of infections or risk thereof. Thus, procedures towards the end of the gender-affirming process, such as  penile prosthesis placement , are usually done separately. [ 19 ]


For people with vaginal cancer, vaginectomy can be done partially, instead of radically, depending on the individual person's need as determined by the tumor's size, location, and stage. For example, some people had simple  hysterectomy  (a procedure that removes a uterus) and then discovered  cervical cancer . At this point, upper vaginectomy - along with other suggested procedures such as  lymphadenectomy  (a procedure that removes lymph nodes) - may be suggested to people who would prefer to keep  ovarian  function intact. [ 20 ]  This is an option depending on the invasiveness and severity of the disease and is specifically for individuals with stage I cancer in the upper vagina. [ 21 ]


Vaginectomy procedures are described by the amount of vaginal tissue removed from an individual which is dependent on the reason for surgery.


For vaginectomy as a treatment to cancer, tissue is removed in response to the extent of the cancer. [ 7 ]  A partial vaginectomy removes only the outer most layers of tissue and is performed if the abnormal cells are only found at the skin level. For example, individuals with rectal cancer that has spread to vaginal tissue may undergo a partial vaginectomy in which the posterior wall of the vagina near the anus is removed. A surgeon will make an incision on the abdomen in order to reach the vagina for removal. The operation to remove vaginal tissue will typically happen with at the same time as a  colostomy  and a  abdominoperineal resection  in which a portion of the colon is rediverted into a colostomy bag and the rectum is removed. A partial vaginectomy leaves much of the muscles in the vagina intact and can be followed by a vaginal reconstruction surgery. [ 22 ]


If more invasive cancer is found, a more complete vaginectomy is performed to remove all cancerous tumors and cells. [ 23 ]


In vaginectomy for gender-affirming surgeries, the tissue from the vaginal wall is removed while outer labial flaps are sometimes left in place for other reconstructive surgeries. [ 24 ]  The procedure gives people who were assigned female sex at birth but do not identify as female, such as transsexual men and transmasculine or otherwise nonbinary individuals, genitalia that aids in reducing gender dysphoria and affirming their gender identity through their physical appearance. [ 3 ] [ 19 ]  Counseling is often provided to people considering gender-affirming surgeries prior to procedures in order to limit regret later down the line. [ 25 ]  In the context of gender-affirming surgery, procedures are categorized as either colpocleisis or total vaginectomy. [ 26 ]


Colpocleisis only removes a layer of epithelium or the outer most tissue in the vaginal canal. The walls of the vaginal canal are then sutured shut, but a small channel and the perineum area between the vagina and anus is typically left open to allow for discharge to be emitted from the body. A colpoclesis procedure is sometimes preceded by an oophorectomy and or a hysterectomy to remove the ovaries and uterus which reduces risks of complications from leaving these structures intact and reduces the amount of vaginal discharge. If the ovaries and uterus are left intact there are greater levels of vaginal discharge remain that can contribute to further gender dysphoria in individuals. [ 26 ]


Total vaginectomy is becoming the more common form of vaginectomy in gender-affirming surgeries. It involves removal of the full thickness of vaginal wall tissue and can be approached vaginally, as in a transvaginal or transperineal vaginectomy, or abdominally through the area near the stomach, as in an abdominal vaginectomy. In addition to a greater degree of tissue removal, total vaginectomy also involves a more complete closure of the space in the vaginal canal. In comparison to colpocleisis, it is more often preceded by separate oophorectomy and hysterectomy procedures and proceeded by a separate gender reconstruction surgery such as to create a neophallus. [ 6 ]   Total vaginectomy surgery is sometimes performed using  robotic assistance  which allows for increased speed and precision for a procedure with less blood loss and a quicker recovery time. [ 26 ]


Individuals should expect to experience some pain in the first week after the operation. The average hospital stay after operation was a week and all individuals are discharged with a  catheter , which is removed after 2–3 weeks. [ 8 ]  At discharge, individuals learn how to take care of the incisions and  must limit their physical activity for the initial 2–3 weeks. Swelling of the abdominal area or abdominal pain are signs of complications during recovery. Some common complications that occur are urethral  fistulas  and  strictures  in individuals who undergo vaginectomy and phallic reconstruction for gender-affirming surgeries. This is due to poor blood supply and improper width of the new urethra. [ 27 ]


Vaginal surgeries have been around throughout medical history. Even before the invention of  modern surgical  techniques such as  anesthesia  and sterile tools, there have been many reports of vaginal surgery to treat problems such as  prolapse , vaginal  fistula , and  poor bladder control . For example, the first documented vaginal hysterectomy was performed in 1521 during the Italian Renaissance. [ 28 ]  Surgical techniques and medical knowledge developed slowly over time until the invention of anesthesia and antisepsis allowed for the age of modern surgery in the mid-nineteenth century. Since then, many techniques and instruments were developed specifically for vaginal surgery like the standardization of  sutures  in 1937 which greatly improved survival rates by lowering risk of infection. [ 29 ]  Noble Sproat Heaney developed the "Heaney Stitch" in 1940 to standardize the technique for vaginal  hysterectomy . The first documented case of radical vaginal surgery was in February 2003 where a person underwent a radical hysterectomy with vaginectomy and reconstruction. [ 30 ]


Vaginectomies are also performed outside of the human species. Similarly to humans, animals may also undergo vaginectomies to treat cancer of the vagina.  Domesticated animals and pets such as dogs, cats, and horses are more likely to receive a vaginectomy because of its complicated procedure. [ 9 ]


Total and partial vaginectomies are not commonly done on dogs as they are complex and are not considered first line therapy however, if other procedures do not work a vaginectomy can be performed on a dog. The most common reasons for a dog to get a vaginectomy include cancer and chronic infection of the vagina. Tumors on the vagina and vulva of the dog accounts for 2.5%-3% of cancers affecting dogs and vaginectomies are one of the treatments to remove and cure the dog. [ 31 ]  Possible complications from the surgery include loss of bladder control, swelling, and improper skin healing. [ 9 ]  However, loss of bladder control was fixed spontaneously within 60 days of the operation and the dogs survived at least 100 days with no disease. [ 31 ]


Warren operation  is a surgery performed to correct  anal incontinence . It is done by  disrupting the anterior segment of the  anal sphincter ,  perineal body  and  rectovaginal septum . [ 1 ]


This technique was first described by Warren in 1875, and got subsequently named after him. It was also called 'Warren flap method' and 'Warren apron technique'. The technique was further modified by Farrar for high lacerations of the rectovaginal septum. [ citation needed ]


Unlike other surgeries for anal incontinence, a preliminary  colostomy  is not necessary for Warren operation. The surgery is planned in such a way that it takes place 2–3 days after the cessation of menstrual flow, such that there is ample time for the surgical wound to heal until the next menses. Succinylsulfathiazole is the recommended intestinal antiseptic given two days before the surgery since it keeps the stool soft in the post-operative period. Enema is given early on the day of surgery. [ citation needed ]


The surgery is performed in jack-knife position, making the vagina and anorectum more accessible. Spinal anaesthesia is usually preferred. After exposing the cervix and posterior wall of the rectum using a Sim's speculum, a Kocher clamp is placed in the posterior vaginal wall just below the cervix. The incision diverges outwards to the anal margin, encloses the anterior third of anal orifice and forms a triangular flap. The mucosal flap is then freed by sharply dissecting into the rectal orifice. Chromic catgut sutures are now places from within outward, including levator muscle fascia, perineal body, Colle's fascia, bulbocavernosus muscles and levator ani. The sutures are pulled up under tension and tied. The retracted ends of external sphincter muscle are now brought closer to the anterior midline of the anus. The ends of the sphincter are sutured together to perineal body. Two sutures are placed in the rectal fascia to lessen the tension on the sphincter ends. The vaginal mucosa is then closed with continuous suture. [ citation needed ]


Cryosurgery  (with  cryo  from the  Ancient Greek   κρύο   ' icy cold ' ) is the use of extreme cold in  surgery  to destroy abnormal or diseased tissue; [ 1 ]  thus, it is the surgical application of  cryoablation .
Cryosurgery has been historically used to treat a number of diseases and disorders, especially  a variety of benign and malignant skin conditions . [ 2 ] [ 3 ]


Warts ,  moles ,  skin tags ,  solar keratoses ,   molluscum , [ 4 ]   Morton's neuroma [ 5 ]  and small  skin cancers  are candidates for cryosurgical treatment. Several  internal disorders  are also treated with cryosurgery, including  liver cancer ,  prostate cancer , lung cancer, oral cancers,  cervical  disorders and, more commonly in the past,  hemorrhoids . Soft tissue conditions such as  plantar fasciitis [ 6 ]  (jogger's heel) and  fibroma  (benign excrescence of connective tissue) can be treated with cryosurgery.


Cryosurgery works by taking advantage of the destructive force of freezing temperatures on  cells . When their  temperature  sinks beyond a certain level  ice crystals  begin forming inside the cells and, because of their lower  density , eventually tear apart those cells. Further harm to malignant growth will result once the  blood vessels  supplying the affected tissue begin to freeze.


Cryosurgery is used to treat a variety of benign skin  lesions  including: [ 3 ]


Cryosurgery may also be used to treat low risk skin cancers such as  basal cell carcinoma  and  squamous cell carcinoma  but a biopsy should be obtained first to confirm the diagnosis, determine the depth of invasion and characterize other high risk histologic features. [ 3 ]


A common method of freezing lesions is by using  liquid nitrogen  as the cryogen. The liquid nitrogen may be applied to lesions using a variety of methods, such as dipping a cotton or synthetic material tipped applicator in liquid nitrogen and then directly applying the cryogen onto the lesion. [ 3 ]  The liquid nitrogen can also be sprayed onto the lesion using a spray canister. The spray canister may utilize a variety of nozzles for different spray patterns. [ 3 ]  A cryoprobe, which is a metal applicator that has been cooled using liquid nitrogen, can also be directly applied onto lesions. [ 3 ]


Carbon dioxide is also available as a spray and is used to treat a variety of benign spots. Less frequently, doctors use  carbon dioxide  "snow" formed into a cylinder or mixed with  acetone  to form a slush that is applied directly to the treated tissue. [ citation needed ]


Recent advances in technology have allowed for the use of  argon  gas to drive ice formation using a principle known as the  Joule-Thomson effect . This gives physicians excellent control of the ice and minimizes complications using ultra-thin 17  gauge  cryoneedles. [ citation needed ]


A mixture of  dimethyl ether  and  propane  is used in some " freeze spray " preparations such as  Dr. Scholl's  Freeze Away. The mixture is stored in an  aerosol spray  type container at room temperature and drops to −41 °C (−42 °F) when dispensed. The mixture is often dispensed into a straw with a cotton-tipped swab. Similar products may use  tetrafluoroethane  or other substances. [ citation needed ]


A number of medical supply companies have developed  cryogen  delivery systems for cryosurgery. Most are based on the use of liquid nitrogen, although some employ the use of proprietary mixtures of gases that combine to form the cryogen.


Cryosurgery is also used to treat internal and external tumors as well as tumors in the bone. To cure internal tumors, a hollow instrument called a cryoprobe is used, which is placed in contact with the tumor. Liquid  nitrogen  or  argon  gas is passed through the cryoprobe.  Ultrasound  or  MRI  is used to guide the cryoprobe and monitor the freezing of the cells. This helps in limiting damage to adjacent healthy tissues. A ball of ice crystals forms around the probe which results in freezing of nearby cells. When it is required to deliver gas to various parts of the tumor, more than one probe is used. After cryosurgery, the frozen tissue is either naturally absorbed by the body in the case of internal tumors, or it dissolves and forms a scab for external tumors. [ 7 ]


Cryosurgery is a  minimally invasive  procedure, and is often preferred to other types of surgery because of its safety, ease of use, minimal pain and scarring as well as low cost; [ 3 ]  however, as with any medical treatment, there are risks involved, primarily that of damage to nearby healthy tissue. Damage to  nerve tissue  is of particular concern but is rare. [ 3 ]


Cryosurgery cannot be used on lesions that would subsequently require biopsy as the technique destroys tissue and precludes the use of  histopathology . [ 3 ]


More common complications of cryosurgery include blistering and edema which are transient. [ 3 ]  Cryosurgery may cause complications due to damage of underlying structures. Destruction of the  basement membrane  may cause scarring and destruction of hair follicles can cause  alopecia  or hair loss. [ 3 ]  Occasionally,  hypopigmentation  may occur in the area of skin treated with cryosurgery, however, this complication is usually transient and often resolves as  melanocytes  migrate and repigment the area over several months. [ 8 ]  Bleeding can also occur, which can be delayed or immediate, due to damage of underlying arteries and arterioles. [ 3 ]  Tendon rupture and cartillage necrosis can occur, particularly if cryosurgery is done over bony prominences. [ 3 ]  These complications can be avoided or minimized if freeze times of less than 30 seconds are used during cryosurgery. [ 3 ]


Patients undergoing cryosurgery usually experience redness and minor-to-moderate localized pain, which most of the time can be alleviated sufficiently by oral administration of mild  analgesics  such as  ibuprofen ,  codeine  or  acetaminophen  (paracetamol).  Blisters  may form as a result of cryosurgery, but these usually scab over and peel away within a few days.


Electrodesiccation and curettage  ( EDC ,  ED & C , or  ED+C ) is a  medical procedure  commonly performed  by  dermatologists ,  surgeons  and  general practitioners  for the treatment of  basal cell cancers  and  squamous cell cancers  of the skin. [ 1 ]  It provides  desiccation ,  coagulation / cauterization , and  curettage  to remove lesions from the  skin .


A round dull instrument ( curette ) of varying sizes (1 mm to 6 mm) is used to scrape off the cancer down to the dermis. [ 2 ] [ 3 ] [ 4 ]   The scraping is then paused while an  electrosurgical  device like a  hyfrecator  is used next.  Electrocoagulation (electrodesiccation) is performed over the raw surgical ulcer to denature a layer of the dermis and the curette is used again over the surgical ulcer to remove denatured dermis down to living tissue.  In the case of skin cancers, the cautery and electrodesiccation is usually performed three times, or until the surgeon is confident that reasonable  margins  have been achieved. [ 4 ]


The cure rate is highly user dependent. [ 5 ]  The more aggressive the surgeon is at performing EDC, the higher the cure rate. Like standard excision, the wider the  surgical margin , the higher the cure rate. Cure rate for small cancer is higher than cure rate for larger cancers. Cure rate for nodular  basal cell cancer  is higher than for infiltrative basal cell cancer. Essentially, all the prognostic factors that apply to  Mohs surgery  and standard surgical excision will also apply to EDC. [ citation needed ]


The method is quick and easy to perform under local anesthetic.  Used correctly, it can allow for adequate to good cosmetic result on small tumor in certain area.  No sutures are used, so a follow-up visit might not be necessary.  Minimal expense is required.  If recurrence occur, rapid diagnosis is possible as the roots are exposed to the surface, and not buried by surgical closure methods (flaps, etc.). [ 5 ]


As the  surgical margin  is not confirmed by  pathology , the free surgical margin can not be confirmed by an objective  pathology  report.  The recurrence rate for EDC is considered by many ( National Comprehensive Cancer Network ) to be too high for use on many facial regions, and on recurrent  skin cancer . [ 6 ] [ 7 ]    As a surgical ulcer is created and is larger than the original tumor, healing time may be delayed and subsequent scarring obvious. [ citation needed ]


Mohs surgery , developed in 1938 by a  general surgeon ,  Frederic E. Mohs ,  is microscopically controlled surgery used to treat both common and rare types of  skin cancer . During the surgery, after each removal of tissue and while the patient waits, the tissue is examined for cancer cells. That examination dictates the decision for additional tissue removal. Mohs surgery is the gold standard method for obtaining complete margin control during removal of a skin cancer (complete circumferential peripheral and deep margin assessment -  CCPDMA ) using  frozen section   histology . [ 1 ]  CCPDMA or Mohs surgery allows for the removal of a skin cancer with very narrow  surgical margin  and a high cure rate.


The cure rate with Mohs surgery cited by most studies is between 97% and 99.8% for primary  basal-cell carcinoma , the most common type of skin cancer. [ 2 ] : 13   Mohs procedure is also used for  squamous cell carcinoma , but with a lower cure rate. Recurrent basal-cell cancer has a lower cure rate with Mohs surgery, more in the range of 94%. [ 2 ] : 7   It has been used in the removal of  melanoma -in-situ (cure rate 77% to 98% depending on surgeon), and certain types of  melanoma  (cure rate 52%). [ 2 ] : 4  [ 3 ] : 211–20


Other indications for Mohs surgery include  dermatofibrosarcoma protuberans ,  keratoacanthoma , spindle cell tumors,  sebaceous carcinomas ,  microcystic adnexal carcinoma ,  merkel cell carcinoma ,  Paget's disease of the breast ,  atypical fibroxanthoma , and  leiomyosarcoma . [ 3 ] : 193–203  [ 4 ]  Because the Mohs procedure is micrographically controlled, it provides precise removal of the cancerous tissue, while healthy tissue is spared. Mohs surgery can also be more cost effective than other surgical methods, when considering the cost of surgical removal and separate histopathological analysis. However, Mohs surgery should be reserved for the treatment of skin cancers in anatomic areas where tissue preservation is of utmost importance (face, neck, hands, lower legs, feet, genitals). [ 4 ]


Mohs surgery is most commonly used on the head and neck, where its use conserves normal tissue and decreases the risk of recurrence.  For these reasons, it is also considered for skin cancers on hands, feet, ankles, shins, nipples, or genitals. [ 4 ] [ 5 ]   Mohs surgery should not be used on the trunk or extremities for uncomplicated, non-melanoma skin cancer of less than one centimeter in size. [ 4 ] [ 5 ]  On these parts of the body, the risks exceed the benefits of the procedure. [ 4 ] [ 5 ]


In 2012, the American Academy of Dermatology published appropriate use criteria (AUC) on Mohs micrographic surgery in collaboration with the following organizations: American College of Mohs Surgery; American Society for Mohs Surgery; and the American Society for Dermatologic Surgery Association. More than 75 physicians contributed to the development of the Mohs surgery AUC, which were published in the Journal of the American Academy of Dermatology and  Dermatologic Surgery . [ 4 ]


The Australasian College of Dermatologists, in concert with the Australian Mohs Surgery Committee, has also developed evidence based guidelines for Mohs Surgery. [ citation needed ]


The Mohs procedure is a pathology sectioning method that allows for the complete examination of the surgical margin. It is different from the standard  bread loafing  technique of sectioning, where random samples of the surgical margin are examined. [ 6 ] : 112–3  [ 2 ] : 3–4  [ 7 ]


Mohs surgery is performed in four steps:


The procedure is usually performed in a physician's office under local anesthetic. A small scalpel is utilized to cut around the visible tumor. Unlike a normal surgical excision, a Mohs surgery cut is performed at a beveling between 10 and 45 degrees to allow visibility of all skin layers during pathological diagnosis. [ 8 ]  A very small surgical margin is utilized, usually with 1 to 1.5 mm of "free margin" or uninvolved skin. The amount of free margin removed is much less than the usual 4 to 6 mm required for the standard excision of  skin cancers . [ 9 ]  After each surgical removal of tissue, the specimen is processed, cut on the  cryostat  and placed on slides, stained with H&E and then read by the Mohs surgeon/pathologist who examines the sections for cancerous cells. If cancer is found, its location is marked on the map (drawing of the tissue) and the surgeon removes the indicated cancerous tissue from the patient. This procedure is repeated until no further cancer is found. [ 10 ]   The vast majority of cases are then reconstructed by the Mohs surgeon. Some surgeons utilize 100 micrometres between each section, and some utilize 200 micrometres between the first two sections, and 100 micrometres between subsequent sections (10 crank of tissue set at 6 to 10 micrometre is roughly equal to 100 micrometres if one allows for physical compression due to the blade).


The trend in skin surgery over the last 10 years has been to continue  anticoagulants  while performing skin surgery. Most cutaneous bleeding can be controlled with  electrocautery , especially bipolar forceps. The benefit gained by ease of  hemostasis  is weighed against the risk of stopping anticoagulants; and it is generally preferred to continue anticoagulants. [ 11 ]


Few specialists dispute the cure rate for Mohs, especially pathologists familiar with the procedure. [ 6 ] : 116   Extensive studies performed by Mohs involving thousands of patients with both fixed tissue and fresh tissue cases have been reported in the literature. [ 12 ]  Other surgeons repeated the studies with also thousands of cases, with nearly the same results. [ 2 ] [ page needed ]


Clinical 5 year cure rates with Mohs surgery:


These are only a small number of cases reported by Mohs, and numerous other articles by other authors have shown tremendous cure rates for primary basal-cell carcinoma. Studies by Smeet, et al. showing a Mohs cure rate of about 95%, and another study in Sweden showing Mohs cure rate of about 94%. [ 13 ]


Some of Mohs' data revealed a cure rate as low as 96%, but these were often very large tumors, previously treated by other modalities. Some authors claim that their 5-year cure rate for primary basal-cell cancer exceeded 99% while other noted more conservative cure rate of 97%. The quoted cure rate for Mohs surgery on previously treated basal-cell cancer is about 94%. [ 2 ] : 6–7   Reasons for variations in the cure rate include the following.


Mohs surgery is not suitable for all  skin cancers . [ 4 ]


Mohs micrographic surgery is the most reliable form of margin control; utilising a unique frozen section histology processing technique – allowing for the complete examination of 100% of the surgical margin. The method is unique in that it is a simple way to handle soft, hard-to-cut tissue. It is superior to serial bread loafing at a 0.1 mm interval for improved false negative error rate, requiring less time, tissue handling, and fewer glass slides mounted.


The clinical quotes for cure rate of Mohs surgery are from 97% to 99.8% after 5 years for newly diagnosed basal-cell cancer (BCC), decreasing to 94% or less for recurrent basal-cell cancer. Radiation oncologists quote cure rates from 90 to 95% for BCCs less than 1 or 2 cm, and 85 to 90% for BCCs larger than 1 or 2 cm. The  Surgical excision  cure rate varies from 90 to 95% for wide margins (4 to 6 mm) and small tumors, to as low as 70% for narrow margins and large tumors.


Some commentators argue that skin cancer surgery, including Mohs surgery, is overutilised as rates of skin cancer surgery are increasing worldwide. It is unclear if this relates to higher rates of skin cancer, increased vigilance in diagnosis, and increased availability of the procedure, or patient and doctor preferences. The incidence of Mohs surgery increased significantly over the decade between 2004 and 2014. In a sample of 100 Mohs surgeries, the total cost ranged from US$474 to US$7,594, with the higher costs for hospital-based complex procedures. In Australia, the direct out of pocket cost to patients may vary from $0 to $4000. When the non-Mohs surgery is performed by multiple doctors including pathologists the costs may be increased further. This is especially true when the cancer is incompletely excised and requires repeat surgery.


Originally, Mohs used a chemical paste (an  escharotic  agent) to cauterize and kill the tissue. It was made of  zinc chloride  and  bloodroot  (the root of the plant  Sanguinaria canadensis , which contains the alkaloid  sanguinarine ). The original ingredients were 40.0 g  Stibnite , 10.0 g  Sanguinaria canadensis , and 34.5 ml of saturated zinc chloride solution. [ 12 ] : 3–6


This paste is similar to  black salve  or "Hoxsey's paste" (see  Hoxsey Therapy ), a fraudulent  patent medicine , but its usage is different. Hoxsey used the paste for long periods, a harmful practice that was rapidly discredited. [ 16 ]  Mohs left the paste on the wound only overnight, and the following day, the cancer and surrounding skin would be anesthetized and the cancer removed. The specimen was then excised, and the tissue examined under the microscope. If cancer remained, more paste was applied, and the patient would return the following day. Later, local anesthetic and frozen section histopathology applied to fresh tissue allowed the procedure to be performed the same day, with less tissue destruction, and similar cure rate. [ 2 ] : 3–4


Photorejuvenation  is a skin treatment that uses  lasers ,  intense pulsed light , or  photodynamic therapy  to treat  skin conditions  and remove effects of  photoaging  such as  wrinkles , spots, and textures.  The process induces controlled  wounds  to the skin. This prompts the skin to heal itself, by creating new cells. This process—to a certain extent—removes the signs of photoaging. [ 1 ]  The technique was invented by Thomas L Roberts, III using  CO 2  lasers  in the 1990s. [ 2 ] [ 3 ]  Observed complications have included  scarring ,  hyperpigmentation ,  acne , and  herpes .


Skin rejuvenation can be effected through various modalities, including thermal, chemical, mechanical, injection, and light. [ 4 ]


Laser resurfacing is a  laser surgery  technique that disassociates  molecular bonds . It is used for the treatment of wrinkles,  solar lentigenes ,  sun damage ,  scarring  ( acne scars  and surgical scars),  stretch marks ,  actinic keratosis , and  telangiectasias .  It can be combined with  liposuction  to help tighten and smooth over the new contours after removal of excess fat. Resurfacing can be ablative, which vaporizes tissue and creates wounds, or non-ablative which keeps the skin intact.


Laser resurfacing is usually done with a 2940 nm  Er:YAG laser  or a 10,600 nm CO 2  laser.  Complete resurfacing was first done with a CO 2  laser. Both erbium and CO 2  are used to treat deep  rhytides ,  sun damage  and  age spots . Through the heating of the deep  dermis ,  fibroblasts  are stimulated to form new  collagen  and  elastin  helping to bring increased turgor and thickness to the skin. A variety of modes have been developed including Nd:Yag lasers and a plasma device. [ 5 ]


CO 2  resurfacing has been shown to have an increased risk of  hypopigmentation  and scarring than erbium lasers. This is due to the high degree of coagulation and thus heat production that occurs as a nature of the CO 2  wavelength.


Fractional laser  photothermolysis  (FP) is a form of laser-based skin resurfacing, with several devices on the market, such as  Fraxel . A fractional laser delivers laser light to the skin. Hundreds or thousands of laser pinpoints may be used per square inch, leaving healthy skin between the  ablated  areas.


Complications observed in a study of 961 treatments included  acne  and  herpes  outbreaks. [ 6 ]  There have been anecdotal negative accounts of bad scarring and  hyperpigmentation . [ 7 ]


Erbium and CO 2  fractional systems have a better safety profile than lasers of the past. [ 8 ]


Intense Pulsed Light  (IPL) uses flashlamps (and not lasers) to produce high intensity light over broad visible and infrared wavelengths with filters that select the desired range.  IPL is used to treat dyschromia, rosacea, melasma, acne, photodamage, vascular and pigmented lesions, and rhytides. [ 9 ]


One study conducted by a group of four researchers from the  Weill Cornell Medical College of Cornell University  in 2004 found IPL to be a "non-invasive, non-ablative method for rejuvenating photoaged skin with minimal adverse events". [ 10 ]


Other studies, however, have noted that exposing cells to direct heat can cause  DNA  damage—not only in those cells, but also in surrounding tissue that was not directly exposed, and concluded treatments can cause microscopic thermal injuries, and that further research is warranted. [ 11 ]


IPL is effective for pigmentation and telangiectasias, but has lesser results for wrinkles. [ 12 ]


Photodynamic therapy  (PDT) uses photosensitive compounds that are activated by light.  It is used to treat  actinic keratoses , acne, photoaging, and skin cancer.


Skin biopsy  is a  biopsy  technique in which a  skin lesion  is removed to be sent to a  pathologist  to render a microscopic  diagnosis .  It is usually done under  local anesthetic  in a physician's office, and results are often available in 4 to 10 days.  It is commonly performed by  dermatologists .  Skin biopsies are also done by family physicians, internists, surgeons, and other specialties.  However, performed incorrectly, and without appropriate clinical information, a pathologist's interpretation of a skin biopsy can be severely limited, and therefore doctors and patients may forgo traditional biopsy techniques and instead choose  Mohs surgery .


There are four main types of skin biopsies: shave biopsy, punch biopsy, excisional biopsy, and incisional biopsy.  The choice of the different skin biopsies is dependent on the suspected diagnosis of the skin lesion.  Like most biopsies,  patient consent  and  anesthesia  (usually  lidocaine  injected into the skin) are prerequisites. [ citation needed ]


A shave biopsy is done with either a small  scalpel  blade or a curved razor blade.  The technique is very much user skill dependent, as some surgeons can remove a small fragment of skin with minimal blemish using any one of the above tools, while others have great difficulty securing the devices.  Ideally, the razor will shave only a small fragment of protruding tumor and leave the skin relatively flat after the procedure.   Hemostasis  is obtained using light  electrocautery ,  Monsel's solution , or  aluminum chloride .  This is the ideal method of diagnosis for  basal cell cancer .  It can be used to diagnose  squamous cell carcinoma  and  melanoma-in-situ , however, the doctor's understanding of the growth of these last two cancers should be considered before one uses the shave method.  The punch or incisional method is better for the latter two cancers as a false negative is less likely to occur (i.e. calling a squamous cell cancer an  actinic keratosis  or  keratinous  debris).  Hemostasis for the shave technique can be difficult if one relies on electrocautery alone.  A small "shave" biopsy often ends up being a large burn defect when the surgeon tries to control the bleeding with electrocautery alone.  Pressure dressing or chemical  astringent  can help in hemostasis in patients taking  anticoagulants . [ citation needed ]


A punch biopsy is done with a circular blade ranging in size from 1 mm to 8 mm. The blade, which is attached to a pencil-like handle, is rotated down through the epidermis and dermis, and into the  subcutaneous fat , producing a cylindrical core of tissue. [ 1 ]  An incision made with a punch biopsy is easily closed with one or two  sutures .
Some punch biopsies are shaped like an ellipse, although one can accomplish the same desired shape with a standard scalpel.  The 1 mm and 1.5 mm punch are ideal for locations where cosmetic appearance is difficult to accomplish with the shave method.  Minimal bleeding is noted with the 1 mm punch, and often the wound is left to heal without stitching for the smaller punch biopsies. The disadvantage of the 1 mm punch is that the tissue obtained is almost impossible to see at times due to small size, and the 1.5 mm biopsy is preferred in most cases.  The common punch size used to diagnose most inflammatory skin conditions is the 3.5 or 4 mm punch. [ citation needed ] [ 2 ]


In an incisional biopsy a cut is made through the entire  dermis  down to the subcutaneous fat.  A punch biopsy is essentially an incisional biopsy, except it is round rather than elliptical as in most incisional biopsies done with a scalpel.  Incisional biopsies can include the whole lesion (excisional), part of a lesion, or part of the affected skin plus part of the normal skin (to show the interface between normal and abnormal skin).  Incisional biopsy often yield better diagnosis for deep pannicular skin diseases and more subcutaneous tissue can be obtained than a punch biopsy.  Long and thin deep incisional biopsy are excellent on the lower extremities as they allow a large amount of tissue to be harvested with minimal tension on the surgical wound.  Advantage of the incisional biopsy over the punch method is that hemostasis can be done more easily due to better visualization.  Dog ear defects are rarely seen in incisional biopsies with length at least twice as long as the width. [ citation needed ]


An excisional biopsy is essentially the same as incisional biopsy, except the entire lesion or tumor is included.  This is the ideal method of diagnosis of small melanomas (when performed as an excision).  Ideally, an entire melanoma should be submitted for diagnosis if it can be done safely and cosmetically.  This  excisional  biopsy is often done with a narrow  surgical margin  to make sure the deepest thickness of the melanoma is given before prognosis is decided.  However, as many  melanoma -in-situs are large and on the face, a physician will often choose to do multiple small punch biopsies before committing to a large excision for diagnostic purpose alone. Many prefer the small punch method for initial diagnostic value before resorting to the excisional biopsy.  An initial small punch biopsy of a melanoma might say "severe cellular atypia, recommend wider excision".  At this point, the clinician can be confident that an excisional biopsy can be performed without risking committing a " false positive " clinical diagnosis. [ citation needed ]


In table above, each top image shows recommended lines for cutting out slices to be submitted for further processing. Bottom image shows which side of the slice that should be put to  microtomy . Dashed lines here mean that either side could be used. The entire specimen may be sliced and submitted if the risk of malignancy is high. [ 3 ]  Otherwise the rest may be saved in  fixation  in case microscopy indicates further sampling. [ citation needed ]


A curettage biopsy can be done on the surface of tumors or on small epidermal lesions with minimal to no  topical anesthetic  using a round  curette  blade.  Diagnosis of basal cell cancer can be made with some limitation, as morphology of the tumor is often disrupted.  The pathologist must be informed about the type of anesthetic used, as topical anesthetic can cause artifact in the epidermal cells.   Liquid nitrogen  or  cryotherapy  can be used as a topical anesthetic, however, freezing artifacts can severely hamper the diagnosis of malignant skin cancers. [ citation needed ]


Needle aspiration biopsy  is done with the rapid stabbing motion of the hand guiding a needle tipped syringe and the rapid sucking motion applied to the syringe.  It is a method used to diagnose tumor deep in the skin or  lymph nodes  under the skin.  The cellular aspirate is mounted on a glass slide and immediate diagnosis can be made with proper staining or submitted to a laboratory for final diagnosis.  A fine needle aspirate can be done with simply a small  bore  needle and a small syringe (1 cc) that can generate rapid changes in suction pressure.  Fine needle aspirate can be used to distinguish a cystic lesion from a  lipoma .  Both the surgeon and the pathologist must be familiar with the method of procuring, fixing, and reading of the slide.  Many centers have dedicated teams used in the harvest of fine needle aspirate. [ citation needed ]


A saucerization biopsy is also known as "scoop", "scallop", or "shave" excisional biopsy, [ 4 ]  or "shave" excision.  A trend has occurred in dermatology over the last 10 years with the advocacy of a deep shave excision of a pigmented lesion. [ 5 ] [ 6 ] [ 7 ]  An author published the result of this method and advocated it as better than standard excision and less time-consuming.  The added economic benefit is that many surgeons bill the procedure as an excision, rather than a shave biopsy.  This saves the added time for hemostasis, instruments, and suture cost.  The great disadvantage, seen years later, is the numerous scallop scars, and the appearance of a lesion called a " recurrent melanocytic nevus "; many "shave" excisions do not penetrate the dermis or subcutaneous fat enough to include the entire melanocytic lesion, and residual melanocytes regrow into the scar.  The combination of scarring, inflammation, blood vessels, and atypical pigmented streaks seen in these recurrent nevi may result in the dermatoscopic appearance of a melanoma. [ 8 ] [ 9 ] [ 10 ] [ 11 ]  When a second physician later examines the patient, he or she has no choice but to recommend re-excision of the scar.  If one does not have access to the original pathology report, it is impossible to distinguish a recurring nevus from a severely  dysplastic  nevus or melanoma.  As the procedure is widely practiced, it is not unusual to see a patient with dozens of scallop scars, with as many as 20% of them showing residual pigmentation.  The second issue with the shave excision is fat  herniation ,  iatrogenic   anetoderma , and  hypertrophic  scarring.  As the deep shave excision either completely removes the full thickness of the dermis or greatly diminishes the dermal thickness, subcutaneous fat can herniate outward or pucker the skin out in an unattractive way.  In areas prone to friction, this can result in pain, itching, or hypertrophic scarring. [ citation needed ]


A  pathology  report is highly dependent on the quality of the biopsy that is submitted. It is not unusual to miss the diagnosis of a skin tumor or a skin biopsy due to a poorly performed or inappropriately performed skin biopsy. The clinical information provided to the pathologist will also affect the final diagnosis. An example would be a rapidly growing dome shaped tumor of the sun exposed skin. Despite doing a large wedge incision, a pathologist might call the biopsy keratin debris with characteristics of actinic keratosis. But provided with an accurate clinical information, he/she might consider the diagnosis of a well differentiated  squamous cell carcinoma  or  keratoacanthoma . It is not infrequent for two, three or more biopsies to be performed by different doctors for the same skin condition, before the correct diagnosis is made on the final biopsy. The method, depth, and quality of clinical data will all affect the yield of a skin biopsy. For this reason, doctors specializing in skin diseases are invaluable in the diagnosis of skin cancers and difficult skin diseases. Specific stains (PAS, DIF, etc.), and certain type of sectioning (vertical and horizontal) are often requested by an astute physician to make sure that the pathologist will have all the necessary information to make a good histological diagnosis. [ citation needed ]


Pediatric  surgery  is a  subspecialty  of  surgery  involving the surgery of  fetuses ,  infants ,  children ,  adolescents , and  young adults . [ 1 ]


Pediatric surgery arose in the middle of the 1879 century [ clarification needed ]  as the surgical care of  birth defects  required novel techniques and methods, and became more commonly based at children's hospitals. One of the sites of this innovation was the  Children's Hospital of Philadelphia . Beginning in the 1940s under the surgical leadership of  C. Everett Koop , newer techniques for endotracheal  anesthesia  of infants allowed surgical repair of previously untreatable birth defects. By the late 1970s, the infant death rate from several major congenital malformation  syndromes  had been reduced to near zero.


Subspecialties of pediatric surgery itself include:  neonatal  surgery and  fetal surgery .


Other areas of surgery also have pediatric specialties of their own that require further training during the residencies and in a fellowship: pediatric cardiothoracic (surgery on the child's heart and/or lungs, including heart and/or lung transplantation), pediatric nephrological surgery (surgery on the child's kidneys and ureters, including renal, or kidney, transplantation), pediatric neurosurgery (surgery on the child's brain, central nervous system, spinal cord, and peripheral nerves), pediatric urological surgery (surgery on the child's urinary bladder and other structures below the kidney necessary for ejaculation), pediatric emergency surgery, surgery involving fetuses or embryos (overlapping with obstetric/gynecological surgery, neonatology, and  maternal-fetal medicine ), surgery involving adolescents or young adults, pediatric hepatological (liver) and gastrointestinal (stomach and intestines) surgery (including liver and intestinal transplantation in children), pediatric orthopedic surgery (muscle and bone surgery in children), pediatric plastic and reconstructive surgery (such as for burns, or for congenital defects like cleft palate not involving the major organs), and pediatric oncological (childhood cancer) surgery.


Common pediatric diseases that may require pediatric surgery include:


The  American Pediatric Surgical Association  is an American professional organization dedicated to  pediatric surgery . It was established in 1970 and had over 1,200 members as of 2015. Its official journal is the  Journal of Pediatric Surgery . [ 1 ]


The  Annals of Pediatric Surgery  is a quarterly  peer-reviewed   medical journal  covering research on  pediatric   surgery . It was established in October 2005 and is the official journal of the  Egyptian Pediatric Surgical Association . [ 1 ]  The  editor-in-chief  is  Essam A. Elhalaby  Tanta University ).


The journal is abstracted and indexed in  Scopus . [ 2 ]


This article about a  pediatrics   journal  is a  stub . You can help Wikipedia by  expanding it .


The  British Association of Paediatric Surgeons  (BAPS) is a registered charity that aims to advance the study and practice of  paediatric surgery .


The organisation was founded in the UK 1953 and included oversees members. [ 1 ]  The idea for the group came up when a group of four British surgeons -  Denis Browne , Robert Zachary, David Waterston and Peter Rickham - attended a meeting of the  American Academy of Pediatrics  the year before. At the time, there were only a few dozen known paediatric surgeons across the world, so they were all invited to join BAPS. [ 2 ]  Its first meeting was held in 1954. [ 3 ]


Aims of the Society have been listed as to the advance the study, practice, and research in child surgery, to promote the teaching of surgery in children, both under-graduate and post-graduate, and advise on the training of paediatric surgeons, advice on matters concerning the children surgical services in the British Isles, and to the promote friendship with overseas paediatric surgeons. [ 3 ]


BAPS is one of several national paediatric surgical organisations affiliated with the  Journal of Pediatric Surgery . [ 4 ]  The organisation awards the  Denis Browne Gold Medal  to recognize outstanding achievement in the field. [ 5 ]  The award is named for  Sir Denis Browne , the first president of the association. The first award, given in 1968, went to surgeon  Robert Edward Gross . [ 6 ]


The  Journal of Pediatric Surgery  is a monthly  peer-reviewed   medical journal  covering  pediatric surgery . It was established in 1966 and is published by  Elsevier . It is the official journal of the Section on Surgery of the  American Academy of Pediatrics , the  British Association of Paediatric Surgeons , the  American Pediatric Surgical Association , the  Canadian Association of Paediatric Surgeons , and the  Pacific Association of Pediatric Surgeons . The  editor-in-chief  is G.W. Holcomb III, MD ( University of Missouri at Kansas City School of Medicine ). According to the  Journal Citation Reports , the journal has a 2015  impact factor  of 1.733. [ 1 ]


Pan-African Paediatric Surgical Association (PAPSA)  is an organisation established in 1994 to promote the practice of  paediatric surgery  in  Africa , improvement of research, interchange of ideas and sharing of knowledge and expertise for the benefit of the children of Africa. [ 1 ]


As of 2024 [update] , there have been 16 annual Paediatric Surgical Conferences [ 2 ]  under PAPSA.


Professor Emmanuel A. Ameh is the President of PAPSA and Professor Milind Chitnis is the general secretary.


During the 38th  British Association of Paediatric Surgeons  (BAPS) conference in  Budapest  in 1991, the concept of an Association representing Africa was proposed with 9 paediatric surgeons from Africa who attended the meeting. [ 1 ]


As the idea needed international recognition and support, the  World Federation of Associations of Pediatric Surgeons  (WOFAPS) gave  support during the development phases of the as yet to be established Association. [ 1 ]


World Federation of Associations of Pediatric Surgeons (WOFAPS)  is an organisation established on 15 October 1974 in  Brazil [ 1 ]  to promote the ethical study of pediatric research and to promote  Pediatric Surgery  as a distinct specialty of general surgery. The Kyoto Declaration of Pediatric Surgery, written in 2001, established the mission of the Federation to focus on the development and education of surgeons serving children, in all parts of the world. [ 2 ]


Several surgeons and associations supported the endorsement of the proposal for the "International Union of Pediatric Surgeons" proposed by Denys Pellerin in  Paris  in 1963. But the progress was slow. On 15 October 1974, WOFAPS was founded in  São Paulo , Brazil, during a Pediatric Surgery Congress with representatives from 43 Countries under the Presidency of Prof. Virgilio Carvalho Pinto and Secretary General Prof. Jose Pinus. Harvey Beardmore from  Canada  was elected the first President of the WOFAPS. [ 3 ]  while Prof Jose "Pepe" Boix Ochoa was again re-elected as General Secretary (a post he would hold for 35 years!!).


Until 1983, only 23 associations belonged to the WOFAPS, but the organization has grown to include over 100 member countries today. It is recognized and participates in International Associations of Pediatric Surgery as a member as well as the International Pediatric Association, as well as other organizations such as  UNICEF ,  UNESCO  and  WHO . This has been due to the past leadership and efforts of the members. [ 4 ]  Notable associations that have joined the WOFAPS include  American Pediatric Surgical Association , EUPSA, the  British Association of Paediatric Surgeons  and the  Deutsche Gesellschaft für Kinderchirurgie  [ de ] , as well as more geographically distributed associations, for example the  Pan-African Paediatric Surgical Association .


The WOFAPS is a representation of Pediatric Surgical Associations and it does not represent any political ideas nor does it make any racial or religious distinction. The WOFAPS is governed by its Constitution and its official office is in  Bern , Switzerland. [ 5 ]


The  WOFAPS Foundation  is a subsidiary of WOFAPS that offers  Scholarships  to International Young Pediatric Surgeons [ 6 ]  from developing countries who have demonstrated strong interests in teaching and research. The WOFAPS foundation is headed by Prof. Prem Puri, [ 7 ]  previous president of WOFAPS and Lifetime Achievement Award recipient in 2013. [ 8 ]


The board is currently led by Prof Alp Numanoglu (South Africa) acting as president, Prof Shilpa Sharma (India) as general secretary and Prof Udo Rolle (Germany) is the president elect for the current term (2022-2025). The WOFAPS executive board consists of 15 Pediatric Surgeons voting members representing all continents and one non voting member as Prof Mahmoud Elfiky (Egypt).


The WOFAPS World Congress is held every three years. However, the WOFAPS joins a regional meeting with another pediatric surgical association every year.


Cardiac surgery , or  cardiovascular surgery , is  surgery  on the  heart  or  great vessels  performed by cardiac  surgeons . It is often used to treat complications of  ischemic heart disease  (for example, with  coronary artery bypass grafting ); to correct  congenital heart disease ; or to treat  valvular heart disease  from various causes, including  endocarditis ,  rheumatic heart disease , [ 1 ]  and  atherosclerosis . [ 2 ]  It also includes  heart transplantation . [ 3 ]


The earliest operations on the  pericardium  (the sac that surrounds the heart) took place in the 19th century and were performed by  Francisco Romero  (1801) in the city of  Almería  (Spain), [ 4 ]   Dominique Jean Larrey  (1810),  Henry Dalton  (1891), and  Daniel Hale Williams  (1893). [ 5 ]  The first surgery on the heart itself was performed by  Axel Cappelen  on 4 September 1895 at  Rikshospitalet  in Kristiania, now  Oslo . Cappelen  ligated  a bleeding  coronary artery  in a 24-year-old man who had been stabbed in the left  axilla  and was in deep  shock  upon arrival. Access was through a left  thoracotomy . The patient awoke and seemed fine for 24 hours but became ill with a  fever  and died three days after the surgery from  mediastinitis . [ 6 ] [ 7 ]


Surgery on the  great vessels  (e.g.,  aortic coarctation  repair,  Blalock–Thomas–Taussig shunt  creation, closure of  patent ductus arteriosus ) became common after the turn of the century. However, operations on the  heart valves  were unknown until, in 1925,  Henry Souttar  operated successfully on a young woman with  mitral valve stenosis . He made an opening in the appendage of the left  atrium  and inserted a finger in order to palpate and explore the damaged  mitral valve . The patient survived for several years, [ 8 ]  but Souttar's colleagues considered the procedure unjustified, and he could not continue. [ 9 ] [ 10 ]


Alfred Blalock ,  Helen Taussig , and  Vivien Thomas  performed the first successful palliative  pediatric  cardiac operation at  Johns Hopkins Hospital  on 29 November 1944, in a one-year-old girl with Tetralogy of Fallot. [ 11 ]   Their work on patient  Eileen Saxon  was dramatically portrayed by  HBO  in the 2004  television film   Something The Lord Made  as the birth of modern cardiac surgery.


Cardiac surgery changed significantly after  World War II . In 1947,  Thomas Sellors  of  Middlesex Hospital  in London operated on a  Tetralogy of Fallot  patient with  pulmonary stenosis  and successfully divided the stenosed  pulmonary valve . In 1948,  Russell Brock , probably unaware of Sellors's work, [ 12 ]  used a specially designed dilator in three cases of pulmonary stenosis. Later that year, he designed a punch to resect a stenosed  infundibulum , which is often associated with Tetralogy of Fallot. Many thousands of these "blind" operations were performed until the introduction of  cardiopulmonary bypass  made direct surgery on valves possible. [ 9 ]


Also in 1948, four surgeons carried out successful operations for mitral valve stenosis resulting from  rheumatic fever .  Horace Smithy  of Charlotte used a  valvulotome  to remove a portion of a patient's mitral valve, [ 13 ]  while three other doctors— Charles Bailey  of  Hahnemann University Hospital  in Philadelphia;  Dwight Harken  in Boston; and Russell Brock of  Guy's Hospital  in London—adopted Souttar's method. All four men began their work independently of one another within a period of a few months. This time, Souttar's technique was widely adopted, with some modifications. [ 9 ] [ 10 ]


The first successful intracardiac correction of a  congenital heart defect  using  hypothermia  was performed by lead surgeon Dr.  F. John Lewis [ 14 ] [ 15 ]  (Dr.  C. Walton Lillehei  assisted) at the  University of Minnesota  on 2 September 1952. In 1953,  Alexander Alexandrovich Vishnevsky  conducted the first cardiac surgery under  local anesthesia . In 1956, Dr. John Carter Callaghan performed the first documented open-heart surgery in Canada. [ 16 ]


Open-heart surgery is any kind of surgery in which a surgeon makes a large incision (cut) in the chest to open the rib cage and operate on the heart. "Open" refers to the chest, not the heart. Depending on the type of surgery, the surgeon also may open the heart. [ 17 ]


Dr.  Wilfred G. Bigelow  of the  University of Toronto  found that procedures involving opening the patient's heart could be performed better in a bloodless and motionless environment. Therefore, during such surgery, the heart is temporarily stopped, and the patient is placed on  cardiopulmonary bypass , meaning a machine pumps their blood and oxygen. Because the machine cannot function the same way as the heart, surgeons try to minimize the time a patient spends on it. [ 18 ]


Cardiopulmonary bypass was developed after surgeons realized the limitations of  hypothermia  in cardiac surgery: Complex intracardiac repairs take time, and the patient needs blood flow to the body (particularly to the brain), as well as heart and lung function. In July 1952,  Forest Dodrill  was the first to use a mechanical pump in a human to bypass the left side of the heart whilst allowing the patient's lungs to oxygenate the blood, in order to operate on the mitral valve. [ 19 ]   In 1953, Dr.  John Heysham Gibbon  of  Jefferson Medical School  in Philadelphia reported the first successful use of  extracorporeal circulation  by means of an  oxygenator , but he abandoned the method after subsequent failures. [ 20 ]  In 1954, Dr. Lillehei performed a series of successful operations with the controlled cross-circulation technique, in which the patient's mother or father was used as a "heart-lung machine". [ 21 ]  Dr.  John W. Kirklin  at the  Mayo Clinic  was the first to use a Gibbon-type pump-oxygenator. [ 20 ] [ 22 ] Russell M. Nelson  became the first surgeon to perform an open heart surgery in  Utah  in 1955. [ 23 ]


Nazih Zuhdi performed the first total intentional hemodilution open-heart surgery on Terry Gene Nix, age 7, on 25 February 1960 at Mercy Hospital in Oklahoma City. The operation was a success; however, Nix died three years later. [ 24 ]  In March 1961, Zuhdi, Carey, and Greer performed open-heart surgery on a child, aged  3 + 1 ⁄ 2 , using the total intentional hemodilution machine.


In the early 1990s, surgeons began to perform  off-pump coronary artery bypass , done without cardiopulmonary bypass. In these operations, the heart continues beating during surgery, but is stabilized to provide an almost still work area in which to connect a conduit vessel that bypasses a blockage. The conduit vessel that is often used is the saphenous vein. This vein is harvested using a technique known as  endoscopic vein harvesting  (EVH).


In 1945, the Soviet pathologist Nikolai Sinitsyn successfully transplanted a heart from one frog to another frog and from one dog to another dog.


Norman Shumway  is widely regarded as the father of human  heart transplantation , although the world's first adult heart transplant was performed by a  South African  cardiac surgeon,  Christiaan Barnard , using techniques developed by Shumway and  Richard Lower . [ 25 ]  Barnard performed the first transplant on  Louis Washkansky  on 3 December 1967 at  Groote Schuur Hospital  in  Cape Town . [ 25 ] [ 26 ]   Adrian Kantrowitz  performed the first pediatric heart transplant on 6 December 1967 at Maimonides Hospital (now  Maimonides Medical Center ) in Brooklyn, New York, barely three days later. [ 25 ]  Shumway performed the first adult heart transplant in the United States on 6 January 1968 at  Stanford University Hospital . [ 25 ]


Coronary artery bypass grafting  (CABG), also called revascularization, is a common surgical procedure to create an alternative path to deliver blood supply to the heart and body, with the goal of preventing  clot formation . This can be done in many ways, and the  arteries  used can be taken from several areas of the body. [ 27 ]  Arteries are typically harvested from the chest, arm, or wrist and then attached to a portion of the coronary artery, relieving pressure and limiting  clotting factors  in that area of the heart. [ 28 ]


The procedure is typically performed because of  coronary artery disease  (CAD), in which a plaque-like substance builds up in the coronary artery, the main pathway carrying oxygen-rich blood to the heart. This can cause a blockage and/or a rupture, which can lead to a  heart attack . [ 28 ]


As an alternative to open-heart surgery, which involves a five- to eight-inch incision in the  chest wall , a surgeon may perform an  endoscopic  procedure by making very small incisions through which a camera and specialized tools are inserted. [ 29 ]


In  robot-assisted heart surgery , a machine controlled by a cardiac surgeon is used to perform a procedure. The main advantage to this is the size of the incision required: three small port holes instead of an incision big enough for the surgeon's hands. [ 30 ]  The use of robotics in heart surgery continues to be evaluated, but early research has shown it to be a safe alternative to traditional techniques. [ 31 ]


As with any surgical procedure, cardiac surgery requires postoperative precautions to avoid complications. Incision care is needed to avoid infection and minimize  scarring .  Swelling  and  loss of appetite  are common. [ 32 ] [ 33 ]


Recovery from open-heart surgery begins with about 48 hours in an  intensive care unit , where  heart rate ,  blood pressure , and oxygen levels are closely monitored.  Chest tubes  are inserted to drain blood around the heart and lungs. After discharge from the hospital,  compression socks  may be recommended in order to regulate blood flow. [ 34 ]


The advancement of cardiac surgery and cardiopulmonary bypass techniques has greatly reduced the mortality rates of these procedures. For instance, repairs of congenital heart defects are currently estimated to have 4–6% mortality rates. [ 35 ] [ 36 ]


A major concern with cardiac surgery is neurological damage.  Stroke  occurs in 2–3% of all people undergoing cardiac surgery, and the rate is higher in patients with other risk factors for stroke. [ 37 ]  A more subtle complication attributed to cardiopulmonary bypass is  postperfusion syndrome , sometimes called "pumphead". The  neurocognitive  symptoms of postperfusion syndrome were initially thought to be permanent, [ 38 ]  but turned out to be transient, with no permanent neurological impairment. [ 39 ]


In order to assess the performance of surgical units and individual surgeons, a popular risk model has been created called the  EuroSCORE . It takes a number of health factors from a patient and, using precalculated  logistic regression  coefficients, attempts to quantify the probability that they will survive to discharge. Within the  United Kingdom , the EuroSCORE was used to give a breakdown of all  cardiothoracic surgery  centres and to indicate whether the units and their individuals surgeons performed within an acceptable range. The results are available on the  Care Quality Commission  website. [ 40 ] [ 41 ]


Another important source of complications are the neuropsychological and psychopathologic changes following open-heart surgery. One example is  Skumin syndrome  [ fr ] , described by  Victor Skumin  in 1978, which is a "cardioprosthetic psychopathological syndrome" [ 42 ]  associated with  mechanical heart valve implants  and characterized by irrational fear,  anxiety ,  depression ,  sleep disorder , and  weakness . [ 43 ] [ 44 ]


Pharmacological and  non-pharmacological  prevention approaches may reduce the risk of atrial fibrillation after an operation and reduce the length of hospital stays, however there is no evidence that this improves mortality. [ 45 ]


Preoperative  physical therapy  may reduce postoperative pulmonary complications, such as  pneumonia  and  atelectasis , in patients undergoing elective cardiac surgery and may decrease the length of hospital stay by more than three days on average. [ 46 ]  There is evidence that quitting  smoking  at least four weeks before surgery may reduce the risk of postoperative complications. [ 47 ]


Beta-blocking medication is sometimes prescribed during cardiac surgery. There is some low certainty evidence that this perioperative blockade of beta-adrenergic receptors may reduce the incidence of  atrial fibrillation  and  ventricular arrhythmias  in patients undergoing cardiac surgery. [ 48 ]


Aortic valve repair  or  aortic valve reconstruction  is the reconstruction of both form and function of a dysfunctional  aortic valve . Most frequently it is used for the treatment of  aortic regurgitation . [ 1 ]  It can also become necessary for the treatment of  aortic aneurysm , less frequently for congenital  aortic stenosis .


An aortic valve repair will realistically be possible in the absence of calcification or shrinking (retraction) of the aortic valve. Thus, congenital aortic stenosis may be treated by aortic valve repair. [ 2 ]  In acquired aortic stenosis valve replacement will be the only realistic option. In most instances, aortic valve repair will be performed for aortic regurgitation (insufficiency). [ 3 ]  Aortic valve repair may also be performed in the treatment of aortic aneurysm or aortic dissection if either aneurysm or dissection involves the aorta close to the valve. [ 4 ]


Indications for aortic valve repair:


The goal of the operation is the improvement of life expectancy and treatment of heart failure as the consequence of dysfunction of the aortic valve. The goal may also be to avert complications of the aorta (rupture or dissection) in the treatment of aneurysm. Repair is a more recent alternative to replacement; in many instances replacement will be the only realistic option because of severe destruction of the valve. [ 6 ]


While replacement of the aortic valve is a safe and reproducible procedure it may still be associated with the long-term occurrence of so-called valve-related complications. The probability of these complications depends on the age of the patient and the type of operation. [ 7 ]  Typical complications are blood clot formation on the valve or dislodgment of thrombus (embolism); bleeding complications are commonly a consequence of "blood-thinning" medication needed to prevent clots ( anticoagulation ). Biologic/tissue replacement valves have a tendency to degenerate, and there is also an increased risk of infections of valve prosthesis (prosthetic valve  endocarditis ).


Compared to the results of valve replacement there will be a minimal tendency towards clot formation after aortic valve repair, and anticoagulation is commonly not necessary, thus minimizing the possibility of bleeding complications. The likelihood of infection of the repaired aortic valve is much lower compared to what is seen after aortic valve replacement. [ 8 ]  A repair procedure may not last forever, but in many instances the durability of an aortic valve repair will markedly exceed that of a biological prosthesis. [ 6 ]


The details of the aortic valve repair procedure depend on the possibility of congenital malformation of the valve, the type and degree of secondary deformation, and the existence of an aortic aneurysm. The goal of the procedure is the restoration of a normal form of the aortic valve, which will then lead to near-normal function and good durability of the repair. A  transesophageal echocardiogram  during the operation and prior to the repair will be important to define the exact deformation of the aortic valve and thus the mechanism of regurgitation. [ citation needed ]


In order to best accommodate the complex geometry of the aortic valve, these procedures are generally performed through open-heart surgery. Minimally invasive procedures limit the ability to precisely judge the form of the aortic valve and will lead to a higher uncertainty regarding function and durability of aortic valve repair. As for aortic valve replacement, the heart-lung machine is usually connected to the patient via aorta and right  atrium . The heart is arrested through  cardioplegia , and the form of the aortic valve is carefully analyzed. Currently documented predicted values for certain aspects of the form of the aortic valve. [ 9 ]  are available. Using these parameters and a good transesophageal echocardiogram the precise mechanism of regurgitation can be determined in most cases. [ 10 ]


Congenital aortic valve stenosis can be treated by aortic valve repair if there is no relevant calcification. [ 2 ]  In this scenario the aortic valve will almost always be unicuspid and the valve configuration must be altered as part of the procedure in order to improve opening of the valve. Because of the unicuspid form of the valve the repair concept will be similar to that of the regurgitant unicuspid valve.


The traditional treatment of congenital aortic stenosis is balloon valvuloplasty or surgical commissurotomy. Both approaches will frequently not eliminate the narrowing of the valve; in addition, they will lead to a variable degree of aortic valve regurgitation which places an additional burden on the heart. In both interventions some of the valve tissue is opened; the peculiar form aspects of unicuspid aortic valves are not taken into consideration. [ 11 ]  The repair approach differs from commissurotomy mainly in that not only valve tissue is divided to improve opening, but also at least an additional commissure (suspension point of the valve) is created for the aortic valve. Thus, a bicuspid valve is created which results in near-normal function of the aortic valve.


The most reproducible concept is the creation of a bicuspid aortic valve with two normal  commissures  and two  cusps . Tissue of the aortic valve is removed or detached from the aorta in places where it is clearly abnormal. The location of a second commissure of normal height is determined; using a patch or the original cusp tissue the cusps are then sutured to the aortic wall in order to create cusps of sufficient tissue and adequate form reaching the new commissure.


In tricuspid aortic valves the anatomy is principally normal; if there is an aneurysm of the ascending aorta the principles of aortic aneurysm will have to be applied. Without aneurysm, the cause of regurgitation is frequently stretching of one or two of the valve components (cusps). Such stretching can be combined with the presence of congenital tissue fenestrations. Additionally, enlargement of the aortic annulus can contribute to valve dysfunction. Shrinkage of the cusps is less frequent in industrial countries; this is currently not well treatable by repair. [ citation needed ]


In surgical treatment, the extent of cusp stretching is exactly determined and then corrected by sutures. Enlargement of the annulus requires its size reduction and stabilization by an annuloplasty. In the case of annular dilatation, the annulus has to be reduced; currently, the largest experience exists with a strong suture that is placed around the annulus and tied to the desired size. Stretching is corrected by plicating sutures to the point that all cusps have a normal configuration. At the end of the operation, the cusp margins should be at an identical height. [ citation needed ]


In bicuspid aortic valve anatomy, there is congenital fusion of two cusps. This fused cusp is exposed to higher than normal stress and will stretch over time as a consequence. This results in aortic valve regurgitation. Annular enlargement is very frequent in this context, and it increases the tendency to leak. As a result of long-standing dysfunction also the normal cusp may undergo deformation and stretch. In half of the affected individuals there is also an aneurysm of the ascending aorta which has to be treated appropriately. [ citation needed ]