The procedure involves an incision made along the temple hairline and continuing down around the front of the ear or following the natural curves of the ear. The typical incision makes an S shape although the incision length and type can differ between surgeons and is individualized for each patient. The incision is made in front of and behind each ear.  Once these cuts are made, the deeper muscle or SMAS tissue is pulled up and back (and possibly trimmed) and sutured into place.  The excess skin is then trimmed off and the incision is closed.  Liposuction may be used to reduce fat from under the chin.  In addition, the muscle bands in the neck may be sutured together to lessen their appearance.
Lifestyle Lift surgeons also perform eyelid surgeries, brow lifting, fractional CO 2  laser skin resurfacing, fat grafting, and chin augmentation. [ 24 ] [ 25 ]


Maxillofacial prosthetist and technologist  is the term used in the  United Kingdom  for a specialist who delivers  facial ,  ocular  and other  prostheses  which restore form and function to the  body .


In the  United States , this specialty is known as  anaplastology .


In the UK, [ 1 ]  the main governing body for the practice of  maxillofacial  prosthetics is the Institute of Maxillofacial Prosthetics and Technologists.


Maxillomandibular advancement  ( MMA ) or  orthognathic surgery , also sometimes called  bimaxillary advancement  ( Bi-Max ), or  maxillomandibular osteotomy  ( MMO ), is a surgical procedure or  sleep surgery  which moves the upper jaw ( maxilla ) and the lower jaw ( mandible ) forward.
The procedure was first used to correct deformities of the facial skeleton to include  malocclusion . In the late 1970s advancement of the lower jaw (mandibular advancement) was noted to improve sleepiness in three patients. Subsequently, maxillomandibular advancement was used for patients with  obstructive sleep apnea .


Currently, maxillomandibular advancement surgery is often performed simultaneously with  genioglossus advancement  (tongue advancement). The genioglossus advancement pulls the tongue forward in a manner that decreases the amount of tongue blockage during sleep. MMA has been demonstrated to be one of the most effective surgical treatments for sleep apnea, due to its high success rate. Nonetheless, the procedure is often used after other forms of treatment have failed (nasal surgeries,  tonsillectomy ,  uvulopalatopharyngoplasty , tongue reduction surgeries).  There is a longer recovery when compared to other sleep apnea surgeries, since the bones of the face have to heal into their new position.


An  oral medicine  or  stomatology  doctor/dentist (or stomatologist) has received additional specialized training and experience in the diagnosis and management of oral mucosal abnormalities (growths, ulcers, infection, allergies, immune-mediated and autoimmune disorders) including oral cancer, salivary gland disorders, temporomandibular disorders (e.g.: problems with the TMJ) and facial pain (due to musculoskeletal or neurologic conditions), taste and smell disorders; and recognition of the oral manifestations of systemic and infectious diseases. It lies at the interface between  medicine  and  dentistry . An oral medicine doctor is trained to diagnose and manage patients with disorders of the orofacial region.


The importance of the mouth in medicine has been recognized since the earliest known medical writings. For example,  Hippocrates ,  Galen  and others considered the tongue to be a " barometer " of health, and emphasized the diagnostic and prognostic importance of the tongue. [ 1 ]  However, oral medicine as a specialization is a relatively new subject area. [ 2 ] : 2   It used to be termed "stomatology" (- stomato-  +  -ology ). [ 2 ] : 1


In some institutions, it is termed "oral medicine and oral diagnosis". [ 2 ] : 1   American physician and dentist,  Thomas E Bond  authored the first book on oral and maxillofacial pathology in 1848, entitled "A Practical Treatise on Dental Medicine". [ 2 ] : 2  [ 3 ]  The term "oral medicine" was not used again until 1868. [ 3 ]   Jonathan Hutchinson  is also considered the father of oral medicine by some. [ 2 ] : 2


Oral medicine grew from a group of New York dentists (primarily periodontists), who were interested in the interactions between medicine and dentistry in the 1940s. [ 4 ]  Before becoming its own specialty in the United States, oral medicine was historically once a subset of the specialty of  periodontics , with many  periodontists  achieving board certification in oral medicine as well as periodontics.  [ citation needed ]


Oral medicine is concerned with clinical diagnosis and non-surgical management of non-dental pathologies affecting the orofacial region (the mouth and the lower face).


Many systemic diseases have signs or symptoms that manifest in the orofacial region. Pathologically, the mouth may be affected by many cutaneous and gastrointestinal conditions. There is also the unique situation of hard tissues penetrating the epithelial continuity (hair and nails are intra-epithelial tissues). The biofilm that covers teeth therefore causes unique pathologic entities known as plaque-induced diseases.


Example conditions that oral medicine is concerned with are lichen planus, Behçet's disease and pemphigus vulgaris. Moreover, it involves the diagnosis and follow-up of pre-malignant lesions of the oral cavity, such as leukoplakias or erythroplakias and of chronic and acute pain conditions such as paroxysmal neuralgias, continuous neuralgias, myofascial pain, atypical facial pain, autonomic cephalalgias, headaches and migraines. Another aspect of the field is managing the dental and oral condition of medically compromised patients such as cancer patients with related oral mucositis, bisphosphonate-related osteonecrosis of the jaws or oral pathology related to radiation therapy. Additionally, it is involved in the diagnosis and management of dry mouth conditions (such as Sjögren's syndrome) and non-dental chronic orofacial pain, such as burning mouth syndrome, trigeminal neuralgia and temporomandibular joint disorder.


It is not uncommon for an individual to experience a lump/swelling in the oral environment. The overall presentation is highly variable and the progression of these lesions can also differ, for example: development of a lesion into a bulla or a malignant neoplasm. Lumps and swellings can occur due to a variety of conditions, both benign and malignant such as:


So as seen above the list is extensive and by no means is this a complete and comprehensive representation of all the possible lumps/swellings that can occur in the mouth as to the means of acquiring a swelling in the mouth. When considering what a lump might be caused by the site of which it has appeared can be of significance. Below are some examples of swellings/lumps which usually are present as specific locations in the oral cavity: [ 8 ]


If there is any suspect or unknown reason as to why a lump has arisen in an individual's mouth it is important to establish when this first was noticed and the accompanied symptoms if any. On examination ensure that there is not an obvious cause to the swelling/lump via a thorough: medical, social, dental and family history, followed by an oral examination. Whilst examining the suspected lesion there are some diagnostic aids to note which can be used to formulate a provisional diagnosis. [ 9 ]  There are many factors taken into consideration in this diagnosis, such as:


Once the surrounding tissues and the immediate management of any lumps/swellings are taken care of, an image of the full extent of the lesion is needed. This is done to establish what the lump/swelling is associated with and to ensure that any damaging probability is kept to a minimum. There are a variety of imaging technique options which are chosen based on the lesion: size, location, growth pattern etc. Some examples of images used are: DPT,  Scintigraphy ,  Sialography ,  Computed Tomography ,  Magnetic Resonance Imaging  and  Ultrasound .


As described some lumps or swellings can be in close relation to anatomical structures. Commonly, Teeth are associated in a lesion which brings about the question – “are they still vital?” In order to clarify, any tooth that is associated with a lump or swelling is vitality tested, examined for any pathology or restorative deficiencies in order to determine the long term prognosis of this tooth and how this might affect treatment of the lump/swelling at hand.


Alongside any radiographs which may be justified, Blood tests may be needed in order to obtain a definitive diagnosis if there is a suspicion of potential  blood dyscrasias  or any endocrinopathy involvement.


Finally, a particularly vital means of diagnosis is a biopsy. These tend to be regularly done in the cases of singular, chronic lesions and are carried out in an urgent manner as lesions of this category have a significant malignant potential. The indications to carry out a biopsy include:


Once a small piece of tissue is removed for the biopsy, it is then microscopically histopathologically examined. [ 9 ]


Australian programs are accredited by the Australian Dental Council (ADC). They are three years in length and culminate with either a master's degree (MDS) or a Doctor of Clinical Dentistry degree (DClinDent). Fellowship can then be obtained with the  Royal Australasian College of Dental Surgeons , FRACDS (Oral Med) and or the  Royal College of Pathologists of Australasia , RCPA.


Canadian programs are accredited by the Canadian Commission on Dental Accreditation (CDAC). They are a minimum of three years in length and usually culminate with a master's (MSc) degree. Currently, only the  University of Toronto ,  McGill University , the  University of Alberta , and the  University of British Columbia  offer programs leading to the specialty. Most residents combine oral medicine programs with oral and maxillofacial pathology programs leading to a dual specialty. Graduates are then eligible to sit for the Fellowship exams with the Royal College of Dentists of Canada (FRCD(C)).


Indian programs are accredited by the Dental Council of India (DCI).Oral Medicine is in conjunction with oral radiology in India and it is taught in both graduate and post graduate levels as Oral Medicine and Radiology. They are three years in length and culminate with a master's degree (MDS) in Oral Medicine and Radiology.


New Zealand has traditionally followed the UK system of dual training (dentistry and medicine) as a requisite for specialty practice; the  University of Otago Faculty of Dentistry  currently offers a 5-year intercalated clinical doctorate/medical degree (DClinDent/MBChB) program. On 9 July 2013, the dental council of New Zealand proposed that the prescribed qualifications for oral medicine be changed to include the new DClinDent in addition to a medical degree, with no requirement for a standard dental degree. [ 10 ]


In the UK, oral medicine is one of the 13 specialties of dentistry recognized by the  General Dental Council  (GDC). [ 11 ]  The GDC defines oral medicine as: "[concerned with] oral health care of patients with chronic recurrent and medically related disorders of the mouth and with their diagnosis and non-surgical management." [ 12 ]  Unlike many other countries, oral medicine physicians in the UK do not usually partake in the dental management of their patients. [ citation needed ]  Some UK oral medicine specialists have dual qualification with both medical and dental degrees. [ 13 ]  However, in 2010 the GDC approved a new curriculum for oral medicine, and a medical degree is no longer a prerequisite for entry into specialist training. [ 14 ]  Specialist training is normally 5 years, although this may be reduced to a minimum of 3 years in recognition of previous training, such as a medical degree. [ 14 ]  In the UK, oral medicine is one of the smallest dental specialties. [ 15 ]  According to the GDC, as of December 2014 there were 69 clinicians registered as specialists in oral medicine. [ 16 ]  As of 2012, there were 16 oral medicine units across the UK, mostly based in  dental teaching hospitals , [ 14 ]  and around 40 practising consultants. [ 15 ]   The British & Irish Society for Oral Medicine  has suggested that there are not enough oral medicine specialists, and that there should be one consultant per million population. [ 15 ]  Competition for the few training posts is keen, although new posts are being created and the number of trainees increased. [ 15 ]


The  American Dental Association  (CODA) accredited programs are a minimum of two years in length. Oral medicine, is an  American Dental Association  recognized speciality, and many oral medicine specialists fulfil a very important role by teaching at dental schools and graduate programs to ensure dentists and other dental specialists receive excellent training in medical topics pertinent to the dental practice. The ADA has recently started a dental practice parameters for world-class quality services. [1]   Archived  2014-05-07 at the  Wayback Machine


Osseointegration  (from Latin  osseus  " bony " and  integrare  "to make whole") is the direct structural and functional connection between living  bone  and the surface of a load-bearing  artificial implant  ("load-bearing" as defined by  Albrektsson  et al. in 1981). A more recent definition (by  Schroeder  et al.) defines osseointegration as "functional  ankylosis  (bone adherence)", where new bone is laid down directly on the implant surface and the implant exhibits  mechanical stability  (i.e., resistance to destabilization by  mechanical agitation  or  shear forces ). Osseointegration has enhanced the science of  medical  bone and  joint replacement  techniques as well as  dental implants  and improving  prosthetics  for  amputees . [ citation needed ]


Osseointegration is also defined as: "the formation of a direct interface between an implant and bone, without intervening soft tissue". [ 1 ]


An  osseointegrated implant  is a type of  implant  defined as "an endosteal implant containing pores into which osteoblasts and supporting connective tissue can migrate". [ 2 ]  Applied to oral implantology, this refers to  bone  grown right up to the  implant  surface without interposed soft tissue layer. No  scar tissue ,  cartilage  or  ligament  fibers are present between the  bone  and implant surface. The direct contact of bone and implant surface can be verified  microscopically . [ citation needed ]


Osseointegration may also be defined as: [ citation needed ]


Osseointegration was first observed—albeit not explicitly stated—by Bothe, Beaton, and Davenport in 1940. [ 3 ] [ 4 ]  Bothe et al. were the first researchers to implant titanium in an animal and remarked how it tended to fuse with bone. [ 3 ] [ 4 ]   Bothe et al. reported that due to the elemental nature of the titanium, its strength, and its hardness, it had great potential to be used as future prosthesis material. [ 3 ] [ 4 ]  Gottlieb Leventhal later described osseointegration in 1951. [ 3 ] [ 5 ]  Leventhal placed titanium screws in rat femurs and said, "At the end of 6 weeks, the screws were slightly tighter than when originally put in; at 12 weeks, the screws were more difficult to remove; and at the end of 16 weeks, the screws were so tight that in one specimen the femur was fractured when an attempt was made to remove the screw. Microscopic examinations of the bone structure revealed no reaction to the implants, the trabeculation appeared to be perfectly normal." [ 3 ] [ 5 ]  The reactions described by Leventhal and Bothe et al. would later be coined into the term "osseointegration" by  Per-Ingvar Brånemark  of Sweden. In 1952, Brånemark did an experiment where he used a titanium implant chamber to study blood flow in rabbit bone. At the end of the experiment, when it became time to remove the titanium chambers from the bone, he discovered that the bone had integrated so completely with the implant that the chamber could not be removed. Brånemark called this "osseointegration", and, like Bothe et al. and Leventhal before him, saw the possibilities for human use. [ 3 ] [ 4 ] [ 5 ]


In  dentistry  the implementation of osseointegration started in the mid-1960s as a result of Brånemark's work. [ 6 ] [ 7 ] [ 8 ] [ 9 ]   In 1965 Brånemark, who was at the time Professor of Anatomy at  University of Gothenburg , placed  dental implants  into the first human patient—Gösta Larsson. This patient had a cleft palate defect and needed implants to support a  palatal obturator . Gösta Larsson died in 2005, with the original implants still in place after 40 years of function. [ 10 ]


In the mid-1970s Brånemark entered into a commercial partnership with the Swedish defense company  Bofors  to manufacture dental implants and the instrumentation required for their placement. Eventually an offshoot of Bofors, Nobel Pharma, was created to concentrate on this product line.  Nobel Pharma subsequently became Nobel Biocare. [ 10 ]


Brånemark spent almost 30 years fighting the scientific community for acceptance of osseointegration as a viable treatment. In Sweden he was often openly ridiculed at science conferences. His university stopped funding for his research, forcing him to open a private clinic to continue treating patients. Eventually an emerging breed of young academics started to notice the work being done in Sweden. Toronto's George Zarb, a Maltese-born Canadian prosthodontist, was instrumental in bringing the concept of osseointegration to the wider world. The 1983 Toronto Conference is generally considered to be the turning point, when finally the worldwide scientific community accepted Brånemark's work. Osseointegration is now a highly predictable and common treatment modality. [ 10 ]  Since 2010,  Professor Munjed Al Muderis  in Sydney, Australia, used a high tensile strength titanium implant with plasma sprayed surface as an intramedullary prosthesis that is inserted into the bone residuum of amputees and then connect through an opening in the skin to a robotic limb prosthesis. This lets amputees mobilize with more comfort and less energy consumption. Al Muderis also published the first series of combining osseointegration prosthesis with Joint replacement enabling below knee amputees with knee arthritis or short residual bone to walk without needing a socket prosthesis. [ 11 ]


On December 7, 2015, two Operation Iraqi Freedom/Operation Enduring Freedom veterans, Bryant Jacobs and Ed Salau, became the first in America to get a  percutaneous  osseointegrated  prosthesis . [ 12 ]  In the first stage, doctors at Salt Lake Veterans Affairs Hospital embedded a titanium stud in the femur of each patient. About six weeks later, they went back and attached the docking mechanism for the prosthesis. [ citation needed ]


In 2021 Professor Al Muderis published a thesis for the requirements for the  Doctor of Medical Science  discussing  Osseointegration for Amputees: Past, Present and Future  -  Basic Science, Innovations in Surgical Technique, Implant Design and Rehabilitation Strategies. [ 13 ]


Osseointegration is a dynamic process in which characteristics of the implant (i.e. macrogeometry, surface properties, etc.) play a role in modulating molecular and cellular behavior. [ 14 ]  While osseointegration has been observed using different materials, it is most often used to describe the reaction of bone tissues to titanium, or titanium coated with calcium phosphate derivatives. [ 15 ]  It was previously thought that titanium implants were retained in bone through the action of mechanical stabilization or interfacial bonding. Alternatively, calcium phosphate coated implants were thought to be stabilized via chemical bonding.  It is now known that both calcium phosphate coated implants and titanium implants are stabilized chemically with bone, either through direct contact between calcium and titanium atoms, or by the bonding to a cement line-like layer at the implant/bone interface. [ 16 ] [ 17 ]  While there are some differences (e.g. like the lack of chondrogenic progenitors), osseointegration occurs through the same mechanisms as bone fracture healing. [ 18 ] [ 19 ]


For osseointegrated  dental implants , metallic, ceramic, and polymeric materials have been used, [ 2 ]  in particular  titanium . [ 20 ]  To be termed osseointegration the connection between the bone and the implant need not be 100%, and the essence of osseointegration derives more from the stability of the fixation than the degree of contact in histologic terms. In short it is a process where clinically asymptomatic rigid fixation of alloplastic materials is achieved, and maintained, in bone during functional loading. [ 21 ]  Implant healing time and initial stability are a function of implant characteristics. For example, implants using a screw-root form design achieve high initial mechanical stability through the action of their screws against bone. Following placement of the implant, healing typically takes several weeks or months before the implant is fully integrated into the bone. [ 22 ] [ 23 ] [ 24 ]  First evidence of integration occurs after a few weeks, while more robust connection is progressively effected over the next months or years. [ 25 ]   Implants that have a screw-root form design result in bone resorption followed by interfacial bone remodeling and growth around the implant. [ 26 ]


Implants using a plateau-root form design (or screw-root form implants with a wide enough gap between the pitch of the screws) undergo a different mode of peri-implant ossification. Unlike the aforementioned screw-root form implants, plateau-root form implants exhibit de novo bone formation on the implant surface. [ 27 ]  The type of bone healing exhibited by plateau-root form implants is known as intramembranous-like healing. [ 26 ]


Though the osseointegrated interface becomes resistant to external shocks over time, it may be damaged by prolonged adverse stimuli and overload, which may cause implant failure. [ 28 ] [ 29 ]   In studies done using "Mini dental implants," it was noted that the absence of micromotion at the bone-implant interface was needed to enable proper osseointegration. [ 30 ]  It was also noted that there is a critical threshold of micromotion above which a fibrous encapsulation process occurs, rather than osseointegration. [ 31 ]


Other complications may arise even in the absence of external impact. One issue is growth of  cement . [ 32 ]  In normal cases, absence of cementum on the implant surface prevents attachment of  collagen  fibers. This is normally the case due to the absence of cementum progenitor cells in the area receiving the implant. However, when such cells are present, cement may form on or around the implant surface, and a functional collagen attachment may attach to it. [ 33 ]


Since 2005, a number of orthopedic device makers have introduced products with  porous metal construction . [ 34 ] [ 35 ] [ 36 ]  Clinical studies on mammals have shown that porous metals, such as titanium foam, may allow formation of vascular systems within the porous area. [ 37 ]  For orthopedic uses, metals such as  tantalum  or  titanium  are often used, as these metals have high  tensile strength  and corrosion resistance with excellent  biocompatibility . [ citation needed ]


The process of osseointegration in metal foams is similar to that in  bone grafts .  The porous bone-like properties of the metal foam contribute to extensive bone infiltration, allowing  osteoblast  activity to take place.  In addition, the porous structure allows for soft tissue adherence and  vascularization  within the implant.  These materials are currently deployed in  hip replacement ,  knee replacement  and  dental implant  surgeries. [ citation needed ]


There are a number of methods used to gauge the level of osseointegration and the subsequent stability of an implant. One widely used diagnostic procedure is percussion analysis, where a dental instrument is tapped against the implant carrier. [ 38 ]  The nature of the ringing that results is used as a qualitative measure of the implant's stability. An integrated implant will elicit a higher pitched "crystal" sound, whereas a non-integrated implant will elicit a dull, low-pitched sound. [ 39 ]


Another method is a reverse torque test, in which the implant carrier is unscrewed. If it fails to unscrew under the reverse torque pressure, the implant is stable. If the implant rotates under the pressure it is deemed a failure and removed. [ 40 ]  This method comes at the risk of fracturing bone that is mid-way in the process of osseointegration. [ 38 ]  It is also unreliable in determining the osseointegration potential of a bone region, as tests have yielded that a rotating implant can go on to be successfully integrated. [ 41 ]


A non-invasive and increasingly implemented diagnostic method is  resonance frequency analysis  (RFA). [ 38 ]  A resonance frequency analyzer device prompts vibrations in a small metal rod temporarily attached to the implant. As the rod vibrates, the probe reads its resonance frequency and translates it into an  implant stability quotient  (ISQ), which ranges from 1–100, with 100 indicating the highest stability state. Values ranging between 57 and 82 are generally considered stable, though each case must be considered independently. [ 38 ]


One of the peculiarities of osseointegrated  prostheses  is that mechanical events at the prosthesis (e.g. touch) are transferred as vibrations through the bone. [ 42 ]
This "osseoperception" means that the prosthesis user regains a more accurate sense of how the prosthesis is interacting with the world. Users of bone-anchored lower limb prostheses report, for example, that they can tell which type of soil they are walking on due to osseoperception. [ 43 ]


Recent research on users of bone-anchored upper and lower limb prostheses showed that this osseoperception is not only mediated by  mechanoreceptors  but also by  auditory receptors . [ 44 ] [ 45 ]  This means that, rather than just feeling mechanical influences on the device, users also hear the movements of their prosthesis. This joint mechanical and auditory sensory perception is likely responsible for the improved environment perception of users of osseointegrated prostheses compared to traditional socket suspended devices. It is not clear, however, to what extent this implicit sensory feedback actually influences prosthesis users in everyday life. [ 46 ]


An  osteotomy  is a surgical  operation  whereby a  bone  is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a  hallux valgus , or to straighten a bone that has healed crookedly following a  fracture . It is also used to correct a  coxa vara ,  genu valgum , and  genu varum . The operation is done under a  general anaesthetic . [ 1 ]


Osteotomy is one method to relieve pain of arthritis, especially of the hip and knee. It is being replaced by joint replacement in the older patient. [ 2 ]


Due to the serious nature of this procedure, recovery may be extensive. Careful consultation with a physician is important in order to ensure proper planning during a recovery phase. Tools exist to assist recovering patients who may have non– weight bearing  requirements and include bedpans, dressing sticks, long-handled shoe-horns, grabbers/reachers and specialized walkers and wheelchairs.


Two main types of osteotomies are used in the correction of hip dysplasias and deformities to improve alignment/interaction of  acetabulum  – (socket) – and femoral head ( femur head ) –  (ball),  innominate osteotomies  and  femoral osteotomies . The bones are cut, reshaped or partially removed to realign the load-bearing surfaces of the joint. [ 3 ]


Adjustments are made to part of the  hip-bone . Many operating methods and variations have been developed.  They are defined by the type of cut and adjustment made. Some acetabular procedures are named after the surgeons who first described them as Salter (R. Salter), Dega (W. Dega), Sutherland (D.H. Sutherland), Chiari (K. Chiari): other names one may encounter are Ludlov, P. Pemberton, and James B. Steele. Some are named after the shape of cut (e.g. Chevron, Wedge) or the way the bones are aligned (Dial=old style rotary dial phone).


A femoral derotation osteotomy can be performed to correct version abnormalities such as excessive anteversion or retroversion of the hip joint. Excessive anteversion of the femur results in anterior instability of the hip joint while excessive retroversion results in femoroacetabular hip impingement. [ 5 ]


A subtrochanteric blade plate or an intramedullary rod can be used to stabilize the osteotomy site in a femoral derotation osteotomy until compete bone healing is achieved; an approach employing an intramedullary rod is much less invasive than one using a subtrochanteric blade plate. [ citation needed ] }


Femoral osteotomies, as the name indicates, involves adjustments made to the femur head and/or the  femur . [ 6 ]


Knee osteotomy is commonly used to realign arthritic damage on one side of the knee. The goal is to shift the patient's body weight off the damaged area to the other side of the knee, where the cartilage is still healthy. Surgeons remove a wedge of the tibia from underneath the healthy side of the knee, which allows the tibia and femur to bend away from the damaged cartilage. [ 7 ]


A model for this is the hinges on a door. When the door is shut, the hinges are flush against the wall. As the door swings open, one side of the door remains pressed against the wall as space opens up on the other side. Removing just a small wedge of bone can "swing" the knee open, pressing the healthy tissue together as space opens up between the femur and tibia on the damaged side so that the arthritic surfaces do not rub against each other. [ citation needed ]


Osteotomy is also used as an alternative treatment to total knee replacement in younger and active patients. Because prosthetic knees may wear out over time, an osteotomy procedure can enable younger, active osteoarthritis patients to continue using the healthy portion of their knee. The procedure can delay the need for a total knee replacement for up to ten years. [ 8 ]


The location of the removed wedge of bone depends on where osteoarthritis has damaged the knee cartilage. The most common type of osteotomy performed on arthritic knees is a high tibial osteotomy, which addresses cartilage damage on the inside (medial) portion of the knee. The procedure usually takes 60 to 90 minutes to perform. [ 9 ]


During a high tibial osteotomy, surgeons remove a wedge of bone from the outside of the knee, which causes the leg to bend slightly inward. This resembles the realigning of a bowlegged knee to a knock-kneed position. The patient's weight is transferred to the outside (lateral) portion of the knee, where the cartilage is still healthy. [ 10 ]


After regional or general anesthesia is administered, the surgical team sterilizes the leg with antibacterial solution.
Surgeons map out the exact size of the bone wedge they will remove, using an X-ray, CT scan, or 3D computer modeling.
A four- to five-inch incision is made down the front and outside of the knee, starting below the kneecap and extending below the top of the shinbone.Guide wires are drilled into the top of the shinbone (tibia plateau) from the outside (lateral side) of the knee. The wires usually outline a triangle form in the shinbone. [ citation needed ]


A standard oscillating saw is run along the guide wires, removing most of the bone wedge from underneath the outside of the knee, below the healthy cartilage. The cartilage surface on the top of the outside (lateral side) of the shinbone is left intact.  The top of the shinbone is then lowered on the outside and attached with surgical staples or screws, depending on the size of the wedge that was removed.  The layers of tissue in the knee are stitched together, usually with absorbable sutures.


A fall or torque to the leg during the first two months after surgery may jeopardize healing. Patients must exercise extreme caution during all activities, including walking, until healing is complete. [ citation needed ]


After rehabilitation, preventing osteoarthritis involves slowing the progression and spread of the disease. Maintaining aerobic cardiovascular fitness has been an effective method for preventing the progression of osteoarthritis. Light, daily exercise is much better for an arthritic knee than occasional, heavy exercise. [ 11 ]


It is especially important to avoid any serious knee injuries, such as torn ligaments or fractured bones, because arthritis can complicate knee injury treatment. High-impact or repetitive stress sports, like football and distance running, should be avoided.


Because osteoarthritis has multiple causes and may be related to genetic factors, no universal prevention tactic exists.


General recommendations include:


This is performed to realign the  mandible  (lower jaw) or  maxilla  (upper jaw) with the rest of the skull and/or teeth. This is usually performed to correct skeletal malocclusions, that is discrepancies in tooth position that cannot be corrected by simple orthodontic movement, and realignment of the  temporomandibular joints , or to correct facial deformities such as mandibular retrognathia. [ 12 ]  There is little scarring, and all of the surgery takes places inside of the mouth.  Orthodontic braces  may have to be worn pre- and post- operation to realign the  teeth  to match the newly realigned jaw.


Chin osteotomy is most often done to correct a vertically short chin.  As opposed to putting an implant on top of the chin bone to bring it forward, an alternative approach is to cut the chin bone itself and bring it forward or other directions as well. It can also be used to lengthen the chin (which is more difficult with an implant) or to shorten or narrow a chin. (which is impossible with an implant). [ 13 ]


Chin osteotomies (cutting the bone and moving it) are done through an incision inside the mouth. It is technically more difficult than an implant and has more swelling and recovery than a simple chin implant. Also, there is usually temporary loss of feeling of the lip and chin after that takes several weeks to months for full return of sensation. [ citation needed ]


In veterinary medicine, osteotomies are frequently performed to address rupture of the canine cranial cruciate ligament, which is analogous to the anterior cruciate ligament. The  tibial plateau leveling osteotomy  and  tibial tuberosity advancement  are two of the most common osteotomy procedures performed in the United States.  Recovery is often 6–8 weeks and the osteotomy can be filled with autologous bone grafts, scaffolds (hydroxyapatite, TR Matrix, etc.) or ceramics. [ 14 ]


Commonly known as a  dental cyst , the  periapical cyst  is the most common  odontogenic cyst .  It may develop rapidly from a  periapical granuloma , as a consequence of untreated chronic  periapical periodontitis . [ 1 ]


Periapical is defined as "the tissues surrounding the  apex  of the root of a  tooth " and a  cyst  is "a pathological cavity lined by  epithelium , having fluid or gaseous content that is not created by the accumulation of pus." [ 2 ]


Most frequently located in the maxillary anterior region, the cyst is caused by  pulpal   necrosis  secondary to  dental caries  or  trauma . Its lining is derived from the  epithelial cell rests of Malassez  which proliferate to form the cyst. [ 2 ]  Such cysts are very common. Although initially asymptomatic, they are clinically significant because secondary  infection  can cause  pain  and damage. In  radiographs , the cyst appears as a radiolucency (dark area) around the apex of a tooth's root. [ 3 ]


Periapical cysts begin as asymptomatic and progress slowly. Subsequent infection of the cyst causes swelling and pain. Initially, the cyst swells to a round hard protrusion, but later on the body resorbs some of the cyst wall, leaving a softer accumulation of fluid underneath the mucous membrane. [ citation needed ]


Secondary [ clarification needed ]  symptoms of periapical cysts include inflammation and infection of the  pulp  causing dental caries. This infection is what causes  necrosis of the pulp . [ 4 ]


Larger cysts may cause bone expansion or displace roots. Discoloration of the affected tooth may also occur. Patient will present negative results to electric and ice test of the affected tooth but will be sensitive to percussion. Surrounding gingival tissue may experience  lymphadenopathy . The  alveolar plate  may exhibit  crepitus  when palpated.


Expansion of the cyst causes erosion of the floor of the maxillary sinus. As soon as it enters the maxillary antrum, the expansion rate increases due to available space for expansion. Performing a percussion test by tapping the affected teeth will cause shooting pain. This is often clinically diagnostic of pulpal infection. [ citation needed ]


Dental cysts are usually caused due to root infection involving  tooth decay . Untreated dental  caries  then allow bacteria to reach the level of the pulp, causing infection. The bacteria gains access to the periapical region of the tooth through deeper infection of the pulp, traveling through the roots. The resulting pulpal  necrosis  causes proliferation of epithelial rests of Malassez which release toxins at the apex of the tooth. The body's inflammatory response will attack the source of the toxins, leading to periapical inflammation. The many cells and proteins that rush to an area of infection create osmotic tension in the periapex which is the source of internal pressure increase at the cyst site.


These lesions can grow large because they apply pressure over the bone, causing  resorption .  The toxins released by the breakdown of granulation tissue are one of the common causes of bone resorption.


There are two schools of thought regarding cyst expansion. [ 5 ]


Periapical cysts develop due to an inflammatory stimulus in 3 stages: [ 4 ]


The definitive mechanism by which cysts grow is under debate; several theories exist.


Pressure and concentration differences between the cystic cavity and the growth surroundings influence fluid movement into the cyst, causing size increase.


a.  Collagenase  (breakdown of collagen) in the jaw bone leads to bone degeneration, providing room for cysts to develop. Substances released by the body's immune system as a result of the connective tissue breakdown, such as  cytokines  and growth factors, contribute to the mobilization and proliferation of epithelial cells in the area.


b. Bone resorption caused by metabolism of acidic substances produced by cysts contributes to cyst growth. Such substances include  Prostaglandin-2  and  Interleukin-1  which are both produced by the cyst itself.


Epithelial cells will form a mass inside the cavity and the innermost cells become deprived of nutrients because they are far from the source of nutrients (the blood vessels). The innermost cells die and form an aggregate of dead tissue.  The inner cells undergo ischemic liquefactive necrosis which creates the cavity space surrounded by growing epithelial cells. This theory is unlikely in the absence of malignant transformation of epithelial cells as it does not follow the existing relationship between connective tissue and epithelium. [ 4 ]


Epithelial cells have an inherent quality to reproduce and cover any connective tissue that is not already lined with epithelia. Formation of an abscess must precede the epithelial proliferation in order for the cells to carry out this tendency. This theory explains why cysts are lined in epithelia but not why the initial cysts itself forms. [ 6 ]


A non-vital tooth is necessary for the diagnosis of a periapical cyst, meaning the nerve has been removed by root canal therapy. [ citation needed ]


The surrounding intraoral anatomical structures should be palpated to identify the presence of bone expansion or displacement of tooth roots as well as  crepitus  noises during examination, indicating extensive bone damage. Bulging of the buccal or lingual cortical plates [ 7 ]  may be present. Age of occurrence in the patient, the location of the cyst, the edges of cystic contours, and the impact that the cyst has on adjacent structures must all be considered for proper diagnosis. [ 3 ]


Several lesions can appear similarly in radiographic appearance. [ 2 ]  Intraoral X-rays or a 3-D cone beam scan of the affected area can be used to obtain radiological images and confirm diagnosis of cysts in the periapical area. Circular or ovoid radiolucency surrounding the root tip of approximately 1-1.5 cm in diameter is indicative of the presence of a periapical cyst. [ 2 ]  The border of the cyst is seen as a narrow opaque margin contiguous with the  lamina dura . In cysts that are actively enlarging, peripheral areas of the margin may not be present. Periapical cysts have a characteristic   unilocular [ 8 ]  shape on radiographs. There is also a severe border of cortication [ 9 ]  between the cyst and surrounding bone. Pseudocysts, on the other hand, have a fluid filled cavity but are not lined by epithelium, therefore they have a less severe and more blurred border between the fluid and bony surroundings. [ 10 ]


In  light microscopy , periapical cysts show: [ 11 ]


They sometimes have the following features: [ 11 ]


Periapical cysts exist in two structurally distinct classes:


Radiographically , it is virtually impossible to differentiate  granuloma  from a cyst. [ 2 ]  If the lesion is large it is more likely to be a cyst. Radiographically, both granulomas and cysts appear radiolucent. Many lesions of the mandible in particular appear cystlike in appearance. It is often necessary to obtain a biopsy and evaluate the tissue under a microscope to accurately identify the lesion. [ 2 ]


The infected tissue of the periapical cyst must be entirely removed, including the epithelium of the cyst wall; otherwise, a relapse is likely to occur. Root canal treatment should be performed on the tooth if it is determined that previous therapy was unsuccessful. Removal of the necrotic pulp and the inflamed tissue as well as proper sealing of the canals and an appropriately fitting crown will allow the tooth to heal under uninfected conditions. [ 2 ]


Surgical options for previously treated teeth that would not benefit from root canal therapy include cystectomy [ 12 ]  and cystostomy. [ 12 ]  This route of treatment is recommended upon discovery of the cyst after inadequate root canal treatment. A cystectomy is the removal of a cyst followed by mucosa and wound closure to reduce chances of cyst regeneration. This type of treatment is more ideal for small cysts. [ citation needed ]
A cystostomy is recommended for larger cysts that compromise important adjacent anatomy. The cyst is tamponaded to allow for the cyst contents to escape the bone. Over time, the cyst decreases in size and bone regenerates in the cavity space.


Marsupialization  could also be performed, which involves suturing the edges of the gingiva surrounding the cyst to remain open. The cyst then drains its contents and heal without being prematurely closed. The end result is the same as the cystostomy, bone regeneration. For both a cystostomy and marsupialization, root resectioning may also be required in cases where root resorption has occurred. [ 13 ]


Periapical cysts comprise approximately 75% of the types of cysts found in the oral region. The ratio of individuals diagnosed with periapical cysts is 3:2 male to female, as well as individuals between 20 and 60 years old. Periapical cysts occur worldwide.


Types of Periapical cysts:


Apical: 70%


Lateral: 20%


Residual: 10%


ReSurge International , formerly known as  Interplast , is an international humanitarian organization that provides free reconstructive surgery in developing countries, primarily to children with  cleft lip and palate  and  burn scar contractures .


ReSurge International, Interplast at the time, was founded in 1969 by  Stanford  plastic surgeon  Donald Laub , and as of 2023, has treated more than 124,000 patients worldwide. The first patient was a 13-year-old boy who had come to  Stanford University Medical Center  from his home in  Mexicali ,  Mexico , to receive surgery to repair his cleft lip and palate. Soon after, Laub and other surgeons began organizing regular trips to a charity hospital in Mexicali to treat children with disabling deformities.


Inherent in the goals of organizations such as ReSurge Inter-national is the supposition that many such disabling conditions can be greatly alleviated or even resolved through plastic surgical intervention. [ 1 ] [ citation needed ]


Interplast was the subject of " A Story of Healing ", winner of the 1997  Academy Award for Documentary Short Subject . Interplast still exists under the Interplast name in Australia. [ citation needed ]


The  splint activator  of Soulet-Besombes is a removable appliance for the treatment of dental and jaw anomalies. It is basically a stylized  Activator appliance , which is however not fitted individually, but is mass-produced in various shapes and sizes. The device is also known as  Position Trainer  or  Kaukraft-Kiefer-Former  (bite-force jaw former, K3F).


The device is made from flexible material as one single piece. At its center, it is completely even and approximates the shape of an ideal dental arch. This flat part is surrounded by ramp-shaped walls. The teeth of the upper and lower jaw bite into the space between these walls accordingly. Normally, there are no individual tooth slots, with the prominent exception of the Australian  Myobrace  design.


The appliance sits passively between the upper and lower jaw, and does not exercise any force by itself to the teeth. When the patient bites together, the teeth standing out of line collide with ramp-shaped walls and are moved into their correct position over time. This works due to the principle of the  inclined plane  and the spring force of the elastic deformation of the device. By biting more or less intensively, the patient can determine themselves how much force is applied.


When the appliance is worn, the lower jaw is positioned into  Angle class  1 relation towards the upper jaw. This is supposed to get the jaw muscles used to this position, and to let the patient learn the correct swallowing pattern. The teeth that in this jaw position do not reach the central plane are allowed to erupt, the same way as they would do with a  bite-plate  applied.


There are special modifications for the treatment of overbite and underbite, however they usually only differ in the shape of the dental arch and in stronger or longer walls.


The device has to be worn at night as well as one hour during daytime. The effect can be increased by doing bite exercises during this time. The wearing comfort is pretty high, however talking is completely impossible. In order to wear the device the patient must be able to breathe through the nose. During the first days, it can fall out of the mouth.


As with any intra-oral appliance, wearing it should not cause sore spots on the  gingiva , as this could lead to permanent tissue damage. If it does cause sores, the parts of the device causing the damage have to be cut off as soon as possible.


In the early 1950s, the French  orthodontists  Prof.  René Soulet  and Prof.  André Besombes  removed the fixed braces of their patients for the time of the summer holidays. In order to stabilize the results achieved so far, they gave them a confectioned rubber retainer to wear at night. To their own surprise, they discovered afterwards that the tooth and jaw anomalies had not only not worsened but even become better during this time. So they improved their construction and called it  Conformateur .


The splint activator is a rather exotic appliance, albeit in recent times, the  Trainer for Kids  (T4K) made by the Australian company  Myofunctional Research  has gained some acceptance in the early treatment of young patients. Some very few practitioners claim that they can successfully treat patients of any age using the splint activator.


Surgical planning  is the preoperative method of pre-visualising a surgical intervention, in order to predefine the surgical steps and furthermore the  bone segment navigation  in the context of  computer-assisted surgery . [ 1 ]
The surgical planning is most important in  neurosurgery  and  oral and maxillofacial surgery . The transfer of the surgical planning to the patient is generally made using a  medical navigation system .


The imagistic  dataset  used for surgical planning is mainly based on a  CT  or  MRI . In  oral and maxillofacial surgery , a different, more "traditional" surgical planning can be used for  orthognatic surgery , based on cast models fixed into an  articulator . [ citation needed ]


In order to make a surgical planning, one would need a  3D  image of the patient. The starting point was made by  G. Hounsfield  in the 1970s, by using  CT  in order to record data about the anatomical situation of the patients. [ 2 ]  In the 1980s, advances were made by the radiologist  M. Vannier  and his team, by creating the first computed three-dimensional reconstruction from a  CT  dataset. [ 3 ]  In the early 1990s, the surgical planning was performed by using  stereolithographic models . [ 4 ]  During the late 1990s, the first  full computer-based  virtual surgical planning was made for  osteotomies , and then transferred to the operating theatre by a  navigation system . [ 5 ]  Currently 3D Printed models are also used to plan a procedure and improve patient outcomes. [ 6 ]


The first commercially available neurosurgical planning systems appeared in the 1990s (the StealthStation by  Medtronic , [ 7 ]  the VectorVision by  Brainlab [ 8 ] ). As newer imaging modalities emerged providing increasing anatomical and functional detail for the patient in the 2000s, these surgical planning systems started to incorporate  virtual reality  technology to facilitate the visualisation and manipulation of the 3D data. One example of such systems is the  Dextroscope , manufactured by  Volume Interactions Pte Ltd . The Dextroscope is mostly used in the planning of complex neurosurgical procedures. [ 9 ] [ 10 ] [ 11 ] [ 12 ]


The  surgical segment navigator (SSN)  is a computer-based system for use in  surgical navigation . It is integrated into a common  platform , together with the surgical tool navigator (STN), the surgical microscope navigator (SMN) and the 6 DOF  manipulator (MKM), developed by  Carl Zeiss .


The  SSN  has been developed as a computer system for  bone segment navigation  in  oral and maxillofacial surgery . [ 1 ]  It allows a very precise repositioning of bone fragments, with the advent of preoperative simulation and  surgical planning . [ 2 ]  The system has been developed since 1997 at the  University of Regensburg, Germany , with the support of the  Carl Zeiss Company . Its principle is based on an infrared localisation system, composed of an  infrared  camera and at least three infrared  transmitters  attached to each bony fragment. The SSN is mainly used in  orthognatic surgery  (surgical correction of dysgnathia), but also for the surgical reconstruction of the orbit, or other surgical interventions to the midface.


Since 2001, at the  University of Heidelberg, Germany , the  SSN++  has been developed, a markerless- registration  navigation system, based on a native (=markerless)  CT  or  MRI . In this case, the  patient registration  is obtained on the operating table, using a surface scanner. [ 3 ]  The SSN++ correlates the surface scan data (gathered on the operating table) with the skin surface reconstruction from the  dataset  obtained preoperatively by  CT  or  MRI . This principle complies with the  terrain contour matching  principle described for flying objects. The advantage of the new method is that the  registration of the patient's position  becomes a simple automated procedure; on the other hand, the radiation load for the patient is reduced, compared to the method using markers. [ 4 ] [ 5 ]


The  zygomaticomaxillary complex fracture , also known as a  quadripod fracture ,  quadramalar fracture , and formerly referred to as a  tripod fracture  or  trimalar fracture , has four components, three of which are directly related to connections between the zygoma and the face, and the fourth being the orbital floor. Its specific locations are the lateral orbital wall (at its superior junction with the  zygomaticofrontal suture  or its inferior junction with the  zygomaticosphenoid suture  at the  sphenoid greater wing ), separation of the maxilla and zygoma at the anterior maxilla (near the  zygomaticomaxillary suture ), the  zygomatic arch , and the  orbital floor  near the  infraorbital canal .


On physical exam, the fracture appears as a loss of cheek projection with increased width of the face. In most cases, there is loss of sensation in the cheek and upper lip due to infraorbital nerve injury. Facial bruising, periorbital ecchymosis, soft tissue gas, swelling,  trismus , altered  mastication ,  diplopia , and   ophthalmoplegia  are other indirect features of the injury. [ 1 ]  The zygomatic arch usually fractures at its weakest point, 1.5 cm behind the zygomaticotemporal suture. [ 2 ]


The cause is usually a direct blow to the  malar eminence  of the cheek during assault. The paired  zygomas  each have two attachments to the cranium, and two attachments to the  maxilla , making up the  orbital floors and lateral walls . These complexes are referred to as the zygomaticomaxillary complex. The upper and transverse maxillary bone has the zygomaticomaxillary and zygomaticotemporal sutures, while the lateral and vertical maxillary bone has the zygomaticomaxillary and frontozygomatic sutures. [ citation needed ]


The formerly used 'tripod fracture' refers to these buttresses, but did not also incorporate the posterior relationship of the zygoma to the sphenoid bone at the zygomaticosphenoid suture. [ citation needed ]


There is an association of ZMC fractures with naso-orbito-ethmoidal fractures (NOE) on the same side as the injury. Concomitant NOE fractures predict a higher incidence of post operative deformity. [ 3 ]


ZMC complex fractures involve the lateral vertical buttress of the ZMC complex (lateral maxillary sinus and lateral orbital wall) and the upper transverse buttress (inferior orbital rim and floor, also including the zygomatic arch). Three of its four components are directly related to connections between the zygoma and the face.


Two of its components are connections between the orbit and mid-face at the orbital medial wall and floor. Unlike an orbital blow out fracture, however, the orbital rim can be involved.  The posterior vertical buttress is usually spared, and is more commonly involved in  Lefort fractures .


Specifically, one of two positions at the lateral orbital wall can be involved, either above at its superior junction with the zygomaticofrontal suture or below at its inferior junction with the zygomaticosphenoid suture at the sphenoid greater wing. Separation of the maxilla and zygoma at the anterior maxilla is also seen near the zygomaticomaxillary suture. The zygomatic arch itself is also transcortically involved, and the orbital floor near the infraorbital canal is disrupted. [ 4 ]


Non-displaced or minimally displaced fractures may be treated conservatively. Open reduction and internal fixation is reserved for cases that are severely angulated or  comminuted . The purpose of fixation is to restore the normal appearance of the face. Specific attention is given to the position of the  malar eminence  and reduction of  orbital  volume by realigning the zygoma and sphenoid. Failure to correct can result in rotational deformity and increase the volume of the orbit, causing the  eye to sink inwards . [ citation needed ]


Fractures with displacement require surgery consisting of fracture reduction with miniplates, microplates and screws. Gillie's approach is used for depressed zygomatic fractures. [ 5 ]  The prognosis of tripod fractures is generally good. In some cases there may be persistent post-surgical facial asymmetry, which can require further treatment. [ 6 ]


Digestive system surgery , or  gastrointestinal surgery , can be divided into upper GI surgery and lower GI surgery. [ 1 ]


Upper gastrointestinal surgery , often referred to as  upper GI surgery , refers to a practice of  surgery  that focuses on the upper parts of the  gastrointestinal tract . There are many operations relevant to the upper gastrointestinal tract that are best done only by those who keep constant practice, owing to their complexity. Consequently, a  general surgeon  may specialise in 'upper GI' by attempting to maintain currency in those skills.


Upper GI surgeons would have an interest in, and may exclusively perform, the following operations:


Surgery on the digestive system's organs is referred to as digestive system surgery, gastrointestinal surgery, or gastrointestinal (GI) surgery. Nutrients from the food we eat are processed and absorbed by the digestive system. Surgery could be required to remedy or treat certain problems or diseases that affect the digestive tract.


There are many different types of digestive system operations, some of the more popular ones being:
1. Appendectomy: The surgical removal of the appendix, typically as a result of acute appendicitis, an appendix inflammation.
2. Gastric bypass: A weight-loss procedure that includes separating the stomach into an upper pouch that is smaller and a lower pouch that is bigger. Then, a section of the stomach and small intestine are skipped in favor of rearranging the small intestine to link to both pouches. As a result, the stomach can contain less food and nutrients are not as well absorbed, which causes weight loss.
3. Cholecystectomy: Surgically removing the gallbladder, frequently as a result of painful gallstones or other problems.
4. Colectomy: The removal of the colon (large intestine) whole or in part. This procedure is typically done to address problems including colorectal cancer, diverticular disease, or inflammatory bowel disease.
5. Resection of the liver in part: This procedure is frequently carried out to treat liver tumors or to remove damaged liver tissue.
6. Esophagectomy: Removal of the esophagus in whole or in part, usually to treat esophageal cancer.
7. Pancreatic Surgery: procedures involving the pancreas, such as the Whipple surgery (pancreaticoduodenectomy), which is used to treat some forms of pancreatic cancer and other serious pancreatic diseases.
8. Hernia Repair: A hernia, which is the protrusion of an organ or tissue through a weak spot in the abdominal wall, is treated surgically.


These operations can be carried out using conventional open surgical procedures or minimally invasive techniques like laparoscopic or robotic-assisted surgery, which require smaller incisions and result in quicker recoveries. Surgery of the digestive system is a complicated topic that calls for specialized education and experience. To make educated decisions regarding their healthcare, individuals must speak with a trained surgeon about their unique situation, treatment options, and potential hazards.


1-800-GET-THIN  was an American marketing company with headquarters at  Beverly Hills , California. It sold weight-loss products and was a  vanity 800 number  as well as a trademarked brand name used to market "insurance services, namely, insurance eligibility review and verification in the health industry." [ 1 ]


Robert Silverman incorporated 1-800-GET-THIN in February 2010. According to Silverman, the goal of 1-800-GET-THIN was "'assisting individuals [to] overcome their battle with obesity, which has reached world-wide epidemic status.'"  Robert Silverman resigned as company president on 28 February 2012 "to pursue other career opportunities." [ 2 ]


On February 2, 2012  Allergan , the manufacturer of  Lap-Band , announced it would no longer sell the device to companies affiliated with 1-800-GET-THIN. [ 3 ] [ 4 ] [ 5 ]


On 7 February 2012, two clinics affiliated with 1-800-GET-THIN halted Lap-Band surgeries. [ 6 ] [ 7 ]  Shortly after that, all previous advertisements, including commercials, were scrubbed off clinic websites and their Youtube channel.


U.S. House  members called for a congressional investigation in 2012 into 1-800-GET-THIN. [ 8 ] [ 9 ] [ 10 ]  The  California Department of Insurance  is investigating surgery centers that are contracted with 1-800-GET-THIN for alleged insurance fraud. [ 11 ] [ 12 ] [ 13 ] [ 14 ]   Published reports and lawsuits speculate that one of the principal surgeons at this enterprise owned and controlled all of the surgery centers, as well as the 1-800-GET-THIN marketing firm. The documents also speculate that ownership of the centers and the marketing firm, 1-800-GET-THIN, are in part controlled by Kambiz Beniamia Omidi. [ 6 ] [ 7 ] [ 14 ] [ 15 ]  In October 2012, the FDA confirmed that members of the 1-800-GET-THIN ad campaign are the subjects of a criminal investigation, involving several federal and state law enforcement agencies, according to a court filing. The investigation is focused on numerous "Potential violations of federal law, including conspiracy, healthcare fraud, wire fraud, mail fraud, tax violations, identity theft, and money laundering," Samanta Kelley, a special agent for the Food and Drug Administration's criminal division, said in an affidavit filed at the federal courthouse in Los Angeles. She also stated that the  FBI  investigated blackmail against 1-800-Get-Thin. [ 16 ]


A former 1-800-GET-THIN client testified in a deposition for a lawsuit that he knew about six or seven deaths that occurred before October 6, 2010, when he says he quit. Two reported deaths occurred after that date, including one still under investigation by the Los Angeles coroner." [ 17 ]  The death still under investigation was that of Paula Rojeski, who died on September 8, 2010, after she underwent a Lap-Band operation at the Valley Surgical Center in West Hills.


No doctors were found of any wrongdoings. As a result, Rojeski's lawsuit was dismissed in 2017.


In 2011, a  class action  lawsuit was filed by relatives of two patients who died after Lap-Band surgeries at clinics affiliated with the 1-800-GET-THIN campaign.  The complaint alleged false advertising and sought damages from the owners and several companies allegedly controlled by them. In April 2013, a settlement was reached to pay approximately $1.3 million to fund compensation for members of the plaintiff class and to fund a billboard campaign warning of the risks of the surgeries. Other lawsuits remain unresolved. [ 18 ]  To this day, no doctor associated with the 1-800-GET-THIN campaign was found guilty of any of the five patient deaths. In addition, there were no medical board accusations alleging wrongdoing by physicians.


From 2011-12, the  U.S. Food and Drug Administration  found that 1-800-GET-THIN's advertisements, LapBandVIP's advertisements, and O-Band's advertisements were all simultaneously misleading and failed to provide accurate information about the potential risks involved in using the product. [ 19 ] [ 20 ]  In 2014 federal prosecutors seized more than $100 million in assets asserted to be related to the business, and in February 2018 Julian Omidi and Mirali Zarrabi were arrested after a federal grand jury indicted them on multiple counts relating to the business' allegedly fraudulent conduct. [ 21 ]


An  abdomino   perineal   resection , formally known as  abdominoperineal resection of the rectum  and  abdominoperineal excision of the  rectum  is a  surgery  for  rectal cancer  or  anal cancer . It is frequently  abbreviated  as  AP resection ,  APR  and  APER .


See image on National Cancer Institute website
The principal indication for AP resection is a rectal carcinoma situated in the distal (lower) one-third of the rectum. [ 1 ]  Other indications include recurrent or residual anal carcinoma ( squamous cell carcinoma ) following initial, usually definitive combination chemoradiotherapy.


APRs involves removal of the  anus , the  rectum  and part of the  sigmoid colon  along with the associated (regional)  lymph nodes , through incisions made in the  abdomen  and  perineum . The end of the remaining  sigmoid colon  is brought out permanently as an opening, called a  stoma , which is used by the patient in conjunction with a  colostomy  pouch, on the surface of the abdomen.


This operation is one of the less commonly performed by  general surgeons , although they are specifically trained to perform this operation. As low case volumes in rectal surgery have been found to be associated with higher complication rates, [ 2 ] [ 3 ]  it is often centralised in larger centres, [ 4 ]  where case volumes are higher.


There are several advantages in terms of outcomes if the surgery can be performed laparoscopically [ 5 ]


An APR, generally, results in a worse  quality of life  than the less invasive  lower anterior resection  (LAR). [ 6 ] [ 7 ]  Thus, LARs are generally the preferred treatment for rectal cancer insofar as this is surgically feasible.


William Ernest Miles  (1869–1947), an English surgeon first performed the surgery of removing the rectum in 1907. He assumed that the rectal cancer can spread in both upwards and downward directions, thus necessitating the removal of the entire rectum together with the anal sphincters, resulting in a permanent stoma by connecting the proximal end of the descending colon to the skin. Mile's operation became the gold standard for treating rectal cancer because his technique successfully reduced the rate of cancer recurrence. [ 8 ] [ 9 ]


To reduce the incidence of death and suffering of the patients associated with the APR procedure,  Henri Albert Hartmann  introduced the anterior resection of the rectum by preserving the distal rectum and anal sphincters, while producing end-sigmoid colostomy. There were attempts to restore bowel continuity by joining the proximal colon with the rectum, but the high incidence of leakage from the anastomotic site caused an increased risk of death to patients. It was only in 1948, Claude Dixon successfully connected the proximal bowel to the rectum, thus allowing patients to have a 64% 5-year survival rate. [ 8 ]


Anal sphincterotomy  is a surgical procedure that involves treating mucosal fissures from the anal canal/ sphincter . [ 1 ] [ 2 ]  The word is formed from sphincter + otomy (to cut, to separate). [ 3 ]


Antrectomy , also called  distal   gastrectomy , is a type of gastric  resection  surgery that involves the removal of the  stomach   antrum  to treat  gastric diseases  causing the damage,  bleeding , or  blockage  of the stomach. [ 1 ] [ 2 ]  This is performed using either the  Billroth I (BI)  or  Billroth II (BII)  reconstruction method. Quite often, antrectomy is used alongside  vagotomy  to maximise its safety and effectiveness. [ 3 ]  Modern antrectomies typically have a high success rate and low  mortality rate , but the exact numbers depend on the specific  conditions  being treated. [ 4 ]


The history of antrectomy traces back to the 19th century, starting with the first successful  gastric resection  in 1810. Since then, antrectomy has undergone a magnitude of changes, where development in the field continues to this day. Even though antrectomy paired with vagotomy and anastomosis is now the established  gold standard , its  side effects  and  clinical relevance  remains a controversial subject. With advancements in alternative surgeries and other non-invasive treatments, antrectomy is less common nowadays.


Generally, an antrectomy is performed to treat  bleeding  and  blockage  of the  stomach . [ 2 ]  This could be caused by a variety of gastric disorders, including:


The  diagnosis  of  stomach  disorders begins with the examination of the patient’s  history  and  family history , and supplemented with a  physical exam . [ 7 ]  Old age and recent significant weight loss would suggest the possibility of  gastric cancer . [ 7 ]  A family history of  duodenal or gastric ulcers  would require the patient to describe the type of discomfort he/she is experiencing. [ 7 ]  Different  stomach disorders  manifest  pain  at different time periods. [ 7 ]


The most common diagnostic tests for stomach disorders include  endoscopy , double-contrast  barium x-ray  study of the upper GI tract, and the detection of  H. pylori  infection . [ 7 ]


A midline  epigastric  incision is first made from the  xiphoid process  of the  sternum  to the  umbilicus . [ 8 ]  The opening can be widened by extending the incision inferiorly. [ 8 ]  When the abdominal organs are exposed, thorough exploration is undertaken to assess the extent of disease and, in the case of  stomach cancer , to confirm resectability. [ 8 ]


Two surgical methods can then be used to perform antrectomy: [ 9 ]


The  gastrocolic ligament  of the  greater omentum  is incised at the middle of the  greater curvature  of the stomach, which opens the  lesser sac . [ 9 ]  The dissection for  gastric ulcers  can be done between the  gastroepiploic vessels  and the gastric wall. [ 9 ]  In carcinoma, the greater omentum corresponding to the extent of the resection of the greater curvature must be removed at the same time. [ 9 ]  The incision continues along the greater curvature towards the duodenum. [ 9 ]  Near the  pylorus  of the stomach, the greater omentum becomes thick and divides into the front and back layer. [ 9 ]  Dissection should be continued bluntly and the right gastroepiploic vessels running between the two layers are ligated. [ 9 ]


The  Kocher manoeuver  is used at a position above or just below the descending (second) part of the duodenum from a lateral direction. [ 9 ]  The duodenum is mobilised to achieve a good general exposure, which facilitates the subsequent gastroduodenostomy. [ 9 ]  The preparation of the free superior (first) part of the duodenum is then continued. [ 9 ]  By stretching the stomach, the dissection proceeds along the greater curvature toward the left medial duodenal wall, then toward the back wall, and finally toward the lateral duodenal wall of the superior part as far as the beginning of the  hepatoduodenal ligament . [ 9 ]  This way, 3 to 5 cm of the back wall of the duodenum can be exposed. [ 9 ]


Dissection is then performed along the lesser curvature of the stomach. [ 9 ]  The  right gastric artery  is divided between  clamps  and ligated. [ 9 ]  The front and back layer of the  lesser (gastrohepatic) omentum  is severed individually. [ 9 ]


The actual resection starts with the cutting of the duodenum between  holding or guy sutures . [ 9 ]  The duodenum is temporarily closed with a sponge; the resection borders of the stomach are then determined. [ 9 ]


A sewing instrument facilitates the final step of stomach removal. [ 9 ]  The incision follows at an angle of 45 degrees to the lesser curvature. [ 9 ]  The staple line can, but need not, be oversewn. [ 9 ]  After removal of the distal portion (including the antrum and the  pylorus ) of the stomach, a clamp is fitted at right angles to the greater curvature. [ 9 ]  The clamp is pushed far enough orally (towards the mouth) for the removal level to correspond in size to the duodenal lumen. [ 9 ]  The remaining aboral (away from the mouth) end is cut off after stay sutures are placed at each cut edge. [ 9 ]  The anastomosis should be performed without clamps. [ 9 ]


The end-to-end gastroduodenostomy is accomplished by anastomosing the duodenum to the end of the greater curvature. [ 9 ]  For this purpose, the two cut surfaces are placed adjacent to each other and two corner stitches are placed, starting at the stomach through the seromuscular layers with tangential grasping of the  mucosa . [ 9 ]  At the duodenum, this stitch is done from inside to outside. [ 9 ]  The corner suture at the lesser curvature is tied, whereas the suture on the opposite side is left open. [ 9 ]  The back wall is reconstructed by interrupted back stitches. [ 9 ]  These stitches start through all layers of the back wall at the cut edge of the lesser curvature from inside to outside and go through all layers of the posterior wall of the duodenum from outside to inside. [ 9 ]  The suture is led back grasping only the mucosa, first of the duodenum and then of the stomach. [ 9 ]  Knotting these sutures leads to an exact coaptation, especially at the level of the mucosa. [ 9 ]  The front wall is best closed with one row of interrupted sutures through all layers with tangential stitches of the mucosa with the same technique as the corner stitches. [ 9 ]  Special attention must be paid to the Jammerecke (angle of sorrow) on the lesser curvature. [ 9 ]


Finally, the anastomosis is checked for patency with the thumb and index finger. [ 9 ]  The position of the  stomach tube  is also checked to ensure it crosses the anastomosis. [ 9 ]  A double-lumen gastric tube is placed across the anastomosis for 2 to 3 days, allowing early enteral nutrition via the distal lumen. [ 9 ]


In difficult duodenal ulcers, it can be impossible to preserve enough duodenal wall to be able to construct a tension-free anastomosis. [ 9 ]  In this situation, it is safer to staple close the duodenum and reconstruct the intestinal passage by end-to-side anastomosis. [ 9 ]  For this purpose, the stomach is removed as previously described; the dissected stomach lumen is then anastomosed onto the front wall of the duodenum. [ 9 ]


Usually, an oblique incision should be made on the duodenal front wall so that the incision level starts from oral–medial and goes to aboral–lateral. [ 9 ]  The suturing technique is the same as for the end-to-side anastomosis. [ 9 ]  In technically difficult duodenal stump closures, additional coverage of the stump with the back wall of the stomach can be obtained. [ 9 ]


Both the left gastric and left gastroepiploic artery are preserved in this method, although the resection is more extended. [ 9 ]


At the oral margin of the dissection line, usually covering two-thirds of the stomach, the resection is completed by transverse application of a linear stapler in a way that the complete stomach is divided between one stapler application. [ 9 ]  The staple line can be oversewn. [ 9 ]


The first or second loop of the  jejunum  is then mobilised and placed tension-free and in a retrocolonic fashion opposite the greater curvature of the remaining stomach. [ 9 ]  The loop should be long enough and should have a Braun jejunojejunostomy between the ascending and the descending loop. [ 9 ]


The last 4 to 5 cm of the stapler line towards the greater curvature should be excised with the help of an electrocautery device in order to form a slim opening for the subsequent gastrojejunostomy. [ 9 ]   Stay sutures  are placed on both sides of the anastomosis. [ 9 ]  The jejunum is incised with the electrocautery device opposite the  mesentery . [ 9 ]


The gastrojejunostomy is performed by single interrupted sutures with resorbable suture material and, as the anastomosis cannot be turned, the back wall is sutured by interrupted mattress sutures and the front wall by extramucosal interrupted sutures. [ 9 ]  Alternatively, continuous suturing with a monofilament resorbable thread on both sides of the anastomosis is possible. [ 9 ]  Before finalisation of the front wall, a double-lumen gastric tube is placed distally to the anastomosis, allowing early enteral nutrition. [ 9 ]  In order to prevent enterogastric (bile) reflux, the formation of a jejunojejunostomosis (Braun anastomosis), side-to-side, and 30 cm aborally of the gastrojejunostomy is mandatory. [ 9 ]  This anastomosis can be either hand-sewn (interrupted or continuous technique, resorbable suture material) or stapled. [ 9 ]


Supplementary operations can be applied alongside antrectomy to maximise its success and effectiveness. One commonly performed is vagotomy (the removal of the vagus nerve), since the  vagus nerve  also plays a key role in gastric juice regulation. While performed separately, vagotomy and antrectomy reduce stomach acid secretion by up to 60%. [ 10 ]  Combining both practices could reduce stomach acid secretion by up to 80% through an  additive effect . [ 10 ]  In some cases, antrectomy can be used alongside  laparoscopic   sleeve gastrectomy  to facilitate weight loss. [ 11 ]  Yet, the clinical relevance of including antrectomy in this procedure remains to be seen. [ 11 ]


The success rate of antrectomy is dependent on the rationale of the surgery. For example, antrectomies that are done to overcome peptic ulcer disease (PUD) have a 95% success rate, while the percentage is higher for  gastric antral vascular ectasia syndrome (GAVE) . [ 4 ]  However, antrectomies that deal with  gastric cancer  or penetrative wounds are not as successful. [ 4 ]  One possible explanation is that these symptoms are usually more severe and therefore harder to treat, no matter the kinds of surgery used. [ 4 ]


Nowadays, the mortality rates for antrectomy are typically low. The death rate of antrectomy for ulcer treatment is 1-2%, while it is 1-3% for gastric cancer. [ 4 ]  Similarly, the chances of developing complications after surgery depend on the reason for the surgery and the type of complication in question. For example, antrectomy for peptic ulcers has a 1-5% chance for the condition to recur, a 12% chance of developing  diarrhea , and a 30-35% chance of developing  Dumping syndromes . [ 4 ]


The clinical basis of antrectomy was laid in the 19th century with the birth of its father -  gastric resection . The first attempt at gastric resection was by German professor and surgeon  Christian Michaelis , whose experiment on removing pylorus in animals to resolve  gastric obstruction  failed. [ 12 ]  In 1810, his student  Daniel Merrem  successfully performed the resection of the  distal   stomach  and reconnected the  duodenum  to the  stomach  in animal experiments. [ 12 ]  The first clinical attempt of a gastric resection occurred in 1879 by French surgeon  Jules-Émile Péan , who unsuccessfully carried out a pylo-rectomy for a cancer patient. [ 12 ]  This was followed by the attempt of Polish surgeon  Ludwik Rydygier , whose gastric resection also ended in the death of his patient. [ 12 ]  It was not until 1881 was the first successful gastrectomy carried out by German physician Theodor Billroth . Billroth first tested gastrectomy surgery on animals in an experiment known as ‘Billroth I gastrectomy’, which resulted in the long-term survival of two out of seven dogs. [ 12 ]  This eventually led to the first successful gastric resection in a patient with stomach cancer, in which the duodenum was cut 1.5 cm away from the tumor and reattached to the stomach with carbolized silk. [ 12 ]  The practice was then quickly applied to Billroth’s clinics, with 19 successful operations out of 41 gastrectomies by 1890. [ 12 ]


Following the success of the first gastric resection, the birth of antrectomy is attributed to a better understanding of the gastrointestinal system in the early 20th century. Upon the discovery of gastrin by  John S. Edkins  in 1906,  E. Klein  published the first report combining  vagotomy  with  gastrectomy  to ease symptoms of excessive gastric juice secretion. [ 13 ]  By 1946, American physicians  Farmer  and  Smithwick  performed the first vagotomy with hemigastrectomy (the removal of one-half of the stomach). [ 13 ]  In the following year,  Herrington  of Vanderbilt University similarly combined vagotomy with the removal of the lower stomach to improve operational effectiveness, sparking the earliest resemblance to the antrectomy performed today. [ 13 ]  During the same period, other variations of Billroth's gastrectomy such as concurrent  gastrojejunal anastomosis  were also transforming the landscape of gastrectomy, with the most notable contributions by surgeons Hofmeister, Polya, von Haberer, and Finsterer. [ 12 ]  These variations influenced the way antrectomy is practiced, specifically the type of surgeries that antrectomy is paired with.


In the subsequent decades, antrectomy continued to evolve with advancements in surgical techniques. The 1950s marked the popularization of diagnostic and operational  laparoscopy  in hospitals and medical training. [ 14 ]  This meant that antrectomy could be performed in a minimally invasive manner. However, complications such as diarrhea in antrectomy continue to be a problem, with a 1952 edition of The  Lancet Review  commenting, 'fashions in the treatment of peptic ulcer come and go, and the surgical problem remains unsolved.' [ 15 ]  Hence the 1950s and 60s also marked the era of comparative studies of stomach surgery in an attempt of finding an effective method with the least side effects. Most notably, the 1968  Leads-York controlled trial  published by The British Medical Journal found that the combination of vagotomy and gastrectomy is superior to other forms of surgery such as gastroenterostomy on the  Visick grading  (scoring system to quantify the symptomatic outcome of peptic ulcer surgery). [ 16 ]


The decades leading up to the present featured shifting applications of antrectomy. With the commercialization of acid-reducing medications such as  antacids  in the late 1970s, the incidence and prevalence of gastric ulcers fell, hence reducing the need for antrectomy. At the same time, British physician David Cowley became the first person to diagnose and treat pseudo- Zollinger-Ellison syndromes  (stomach ulceration and excessive gastric acid production) using antrectomy and vagotomy. [ 17 ]  In the subsequent decades, a better understanding of the Zollinger-Ellison syndrome led to antrectomy becoming one of the key treatment methods for the ailment.


Despite this, advent of newer non-invasive methods of resolving gastric disorders have made antrectomy less relevant nowadays. By 2003, antrectomy is no longer recognized as the first-line treatment for  gastric antral vascular ectasia  (watermelon stomach) and  peptic ulcer disease . [ 4 ]


Antrectomy can reduce  acid secretion  in  PUD  and remove premalignant tissue to reduce gastric cancer odds. [ 1 ]  This offers a permanent method that has a 95% success rate. It also alleviates pain,  hemorrhage , and  anemia  from recurring  stomach   ulcers . For localized cancer cases, antrectomy can eliminate early-stage cancer in the third (lower) portion of the stomach. Moreover, antrectomy is able to treat PUD and  GOO  by the removal of malignant tissues which controls early-stage gastric cancer while retaining sufficient portions of the stomach for adequate digestion and nutrition uptake. Furthermore, treating  obesity  with antrectomy is also becoming more common. Antrectomy is also the immediate and only approach to reconstructing organs from injuries such as stabbing in the lower portion of the stomach.


Antrectomy results in the removal of parts of the stomach, reducing the functions of a normal stomach. Around 30% of patients develop  Dumping syndrome , a condition where food entering the stomach enters the  intestines  prematurely due to a partially removed stomach not maximizing its digestive function. It causes  heartburn ,  nausea ,  fatigue , and  vomiting  after meals. [ 4 ]  In addition, other side effects include  dysphagia , which is when digestive juices in the  duodenum  flow upward to the esophagus, thus  esophageal  lining is irritated. Diarrhea is common, especially in patients who had vagotomy in addition to an antrectomy because the damage of nerves to the  liver  and  gallbladder  causes excess  bile salt  release.


Due to a decrease in gastric function, patients have to adjust to a diet composed of high  protein  and low  carbohydrates . [ 4 ]  They must take more liquids when eating and have small and frequent meals. The decreased gastric function also leads to  malabsorption  and  malnutrition , especially for  iron ,  folate , and  calcium  because acid is important for assimilating these substances. [ 18 ]  Therefore,  weight loss  due to decreased food intake and malnutrition is common in patients in recovery, especially in elderly patients. Additionally,  Bezoar development obstruction  of the digestive tract is also seen in postoperative patients because the fiber and more solid food are not fully digested by the shrunk stomach. [ 4 ]


Other than side effects, the success of antrectomy in treating the target condition is also debatable. Antrectomy removing a part of the stomach does not treat later-stage cancer. [ 19 ]  For PUD patients, antrectomy alone could still cause the recurrence of gastric ulcers, [ 18 ]  even if paired with a vagotomy. Leakage from anastomosis of the resected stomach and small intestines can also occur in some patients


Antrectomy is an invasive surgery that is only performed when patients experience  bleeding ,  perforation ,  obstruction , and  malignancy . Treatment alternatives are based on their diagnosis.


For  gastric outlet obstruction (GOO) ,  balloon dilation  is a new option for treatment.  Endoscopic stenting  is also used as an alternative but due to the chance of re-obstruction and stent migration, [ 20 ]  it is usually performed on patients with shorter life expectancies.


Antrectomy is often not considered a first-line treatment for  PUD  due to the high success rate with usage of  antibiotics  and other medications, [ 21 ]  described below. Suitable candidates for antrectomy are those who failed to recover from treatment with over-the-counter NSAIDs and have severe damage to the  stomach lining . [ 22 ]


"Triple therapy" is a combination of medications to kill bacteria, reduce stomach acid production, and protect the stomach lining. [ 4 ]


For  cancer ,  chemotherapy  is the most common alternative to antrectomy. Antrectomy is suitable for early-stage gastric cancer as complete removal can stop cancer spread. With advancements in endoscopic surgeries,  endoscopic mucosal resection  (EMR) is a  non-invasive  choice that is safer than antrectomy for small tumor removals in the  distal  portion of the stomach. [ 19 ]  For late-stage cancer where malignancy is spread to other organs, chemotherapy is preferred as surgery cannot eliminate cancer. [ 4 ]  Cancer patients’ condition is also considered when making surgical decisions.


Other surgeries can manage GOO. Surgical approaches are decided based on the patient’s condition and the development of the condition. Enteral stents are used to expand the obstruction of the pylorus. Medication is used to protect the stomach lining.


Other medications including  acupuncture ,  ayurvedic medication , and  herbal preparations  used based on the individual’s physique are given as non-invasive treatments in Asian countries and have successful outcomes. [ 4 ]  To manage pain from ulcer and obstruction symptoms, herbalist approaches include  licorice ,  bupleurum ,  fennel ,  fenugreek ,  slippery elm , and  marshmallow root . [ 4 ]


With advancements in endoscopy, traditional antrectomy is a less popular surgical choice for  gastric outlet obstruction (GOO)  and  peptic ulcer disease (PUD) . [ 20 ]


In the past, 89-90% of ulcer-related GOO patients required surgery. [ 24 ]  As the development of  endoscopic procedures  advances, recent reports suggest that endoscopic balloon dilation is an effective treatment option for GOO and PUD.


For Type I, II, and III ulcers,  robot-assisted  gastric antrectomy and  vagotomy  are gaining popularity. This method reduces blood loss and length of stay but the operation duration is longer. [ 21 ]  It carries out exact dissections in a scarred  stomach  and  duodenum  and offers magnification and smooth articulation of instruments. [ 25 ]


Robotic antrectomy first involves a  dissection  along the  greater curvature  of the stomach, from the  pylorus  to the  cephalad  followed by mobilizing the  lesser curvature  and  ligating  the  right gastric artery . [ 25 ]  The duodenal bulb is removed from the pancreas. [ 25 ]  At this point, the proximal transection should extend from the indentation of the  lesser curvature  to the terminal branch of the  right gastroepiploic artery  on the  greater curvature . [ 25 ]  The  distal  transection should be done on the duodenum. [ 25 ]  The antrectomy ends by creating an  anastomosis  for gastrointestinal continuity, usually gastroduodenal or gastrojejunal anastomosis. [ 25 ]


As robotic antrectomy is not popularized in most hospitals,  intracorporeal  antrectomy and anastomosis are the most common for tumor removal and curing complicated PUD as it is comparatively less invasive and minimizes blood loss. The first case of single-incision  laparoscopic antrectomy  for  type I gastric neuroendocrine tumor  was reported in 2021. [ 26 ]


In recent years, antrectomy has been used to control  obesity . [ 27 ]  There are debates on the safety and efficiency of this procedure regarding the distance from the pylorus of which the resection takes place. Trials and reviews have been done on exploring the postoperative effects,  nausea  and  vomiting , and chance of leakage from anastomosis when antrectomy is done 2 cm or less from the pylorus. [ 28 ]  Developments aim to reduce the  stomach  volume in obese patients while retaining digestive function and ensuring safety.


An  appendectomy  ( American English ) or  appendicectomy  ( British English ) is a  surgical operation  in which the  vermiform appendix  (a portion of the intestine) is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat complicated acute  appendicitis . [ 1 ]


Appendectomy may be performed  laparoscopically  (as  minimally invasive surgery ) or as an open operation. [ 2 ]  Over the 2010s, surgical practice has increasingly moved towards routinely offering laparoscopic appendicectomy; for example in the  United Kingdom  over 95% of adult appendicectomies are planned as laparoscopic procedures. [ 3 ]  Laparoscopy is often used if the diagnosis is in doubt, or in order to leave a less visible surgical scar. Recovery may be slightly faster after laparoscopic surgery, although the laparoscopic procedure itself is more expensive and resource-intensive than open surgery and generally takes longer. Advanced pelvic sepsis occasionally requires a lower midline  laparotomy .


Complicated (perforated) appendicitis should undergo prompt surgical intervention. [ 1 ]   There has been significant recent trial evidence that uncomplicated appendicitis can be treated with either antibiotics or appendicectomy, [ 4 ] [ 5 ]  with 51% of those treated with antibiotics avoiding an appendectomy after 3 years. [ 6 ]  After appendicectomy the main difference in treatment is the length of time the antibiotics are administered. For uncomplicated appendicitis, antibiotics should be continued up to 24 hours post-operatively. For complicated appendicitis, antibiotics should be continued for anywhere between 3 and 7 days. [ 1 ]  An interval appendectomy is generally performed 6–8 weeks after conservative management with antibiotics for special cases, such as perforated appendicitis. [ 7 ]  Delay of appendectomy 24 hours after admission for symptoms of appendicitis has not shown to increase risk of perforation or other complications. [ 8 ]


In general terms, the procedure for an open appendectomy is:


The standardization of an incision is not best practice when performing an appendectomy given that the appendix is a mobile organ. [ 9 ]  A physical exam should be performed prior to the operation and the incision should be chosen based on the point of maximal tenderness to palpation. [ 9 ]


These incisions are placed for appendectomy:


Over the past decade, the outcomes of laparoscopic appendectomies have compared favorably to those for open appendectomies because of decreased pain, fewer postoperative complications, shorter hospitalization, earlier mobilization, earlier return to work, and better  cosmesis ; however, despite these advantages, efforts are still being made to decrease abdominal incision and visible scars after laparoscopy. [ 10 ]  Recent research has led to the development of  natural orifice transluminal endoscopic surgery  (NOTES); however, numerous difficulties need to be overcome before a wider clinical application of NOTES is adopted, including complications such as the opening of hollow viscera, failed sutures, a lack of fully developed instrumentation, and the necessity of reliable cost-benefit analyses. [ 11 ]


Many surgeons have attempted to reduce incisional morbidity and improve cosmetic outcomes in laparoscopic appendectomy by using fewer and smaller ports. Kollmar  et al.  described moving laparoscopic incisions to hide them in the natural camouflages like the suprapubic hairline to improve cosmesis. Additionally, reports in the literature indicate that minilaparoscopic appendectomy using 2– or 3-mm or even smaller instruments along with one 12-mm port minimizes pain and improves cosmesis. More recently, studies by Ates  et al.  and Roberts  et al.  have described variants of an  intracorporeal  sling-based single-port laparoscopic appendectomy with good clinical results. [ 11 ]


Also, a trend is increasing towards single-incision laparoscopic surgery (SILS), using a special multiport umbilical trocar. [ 12 ]  With SILS, a more conventional view of the field of surgery is seen compared to NOTES. The equipment used for SILS is familiar to surgeons already doing laparoscopic surgery. Most importantly, it is easy to convert SILS to conventional laparoscopy by adding a few trocars; this conversion to conventional laparoscopy is called 'port rescue'. SILS has been shown to be feasible, reasonably safe, and cosmetically advantageous, compared to standard laparoscopy; however, this newer technique involves specialized instruments and is more difficult to learn because of a loss of triangulation, clashing of instruments, crossing of instruments (cross triangulation), and a lack of maneuverability. [ 11 ]   The additional problem of decreased exposure and the added financial burden of procuring special articulating or curved coaxial instruments exist. SILS is still evolving, being used successfully in many centres, but with some way to go before it becomes mainstream. This limits its widespread use, especially in rural or peripheral centres with limited resources. [ 11 ]


Pediatric patients have a mobile cecum, which allows externalization of the cecal appendix through the umbilicus in most cases. This has led to the development of surgical techniques such as laparoscopic-assisted transumbilical appendectomy, which allows the entire surgery to be performed with a single umbilical incision and has significant advantages in terms of both recovery and aesthetic outcome. [ 13 ]


Appendicitis is the most common emergent general surgery related problem to arise during pregnancy. There is a natural elevation in white blood cell count in addition to anatomical changes of the appendix that occur during pregnancy. [ 14 ]  These findings, in addition to non-specific abdominal symptoms make appendicitis difficult to diagnose. Appendicitis develops most commonly in the second trimester. [ 2 ]  If appendicitis develops in a  pregnant  woman, an appendectomy is usually performed and should not harm the  fetus . [ 15 ]  The risk of premature delivery is about 10%. [ 16 ]  The risk of fetal death in the perioperative period after an appendectomy for early acute appendicitis is 3 to 5%. The risk of fetal death is 20% in perforated appendicitis. [ 17 ]


There has been debate regarding which surgical approach is preferred during pregnancy. Overall, there is no increased risk of fetal loss or preterm delivery with the laparoscopic approach (LA) as compared to the open approach (OA). However, the LA was associated with shorter length of stay in the hospital as well as reduced risk of wound infection. [ 2 ]


Patient positioning is of utmost importance to ensure safety of the fetus during the procedure. This is especially important during the third trimester due to the potential of compression of the inferior vena cava leading by the enlarged uterus. Placing the patient in a 30-degree left lateral decubitus position alleviates this pressure and prevents fetal distress. [ 14 ]


One area of concern related to the LA during pregnancy is  pneumoperitoneum . This causes an increase in the intra-abdominal pressure, leading to decreased venous return and therefore, decreased cardiac output. The decreased cardiac output may lead to fetal acidosis and cause distress. However, an animal pregnancy model demonstrated that a 10-12mmHg insufflation pressure demonstrated no adverse effects on the fetus. SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) currently recommends an insufflation pressure of 10-15mmHg during pregnancy. [ 2 ]


A study from 2010 found that the average hospital stay for people with appendicitis in the United States was 1.8 days. For people with a perforated (ruptured) appendix, the average length of stay was 5.2 days. [ 18 ]


Recovery time from the operation varies from person to person. Some take up to three weeks before being completely active; for others, it can be a matter of days. In the case of a laparoscopic operation, the patient has three stapled scars of about an inch (2.5 cm) in length, between the navel and pubic hair line. When an open appendectomy has been performed, the patient has a 2– to 3-inch (5–7.5 cm) scar, which will initially be heavily bruised. [ 19 ]


One of the most common post-operative complications associated with an appendectomy is the development of a surgical site infection (SSI). [ 20 ]  Signs and symptoms indicative of a superficial SSI are redness, swelling, and tenderness surrounding the incision and are most likely to arise on post-operative day 4 or 5. These symptoms oftentimes precede fluid drainage from the incision. Tenderness extending beyond the redness that surrounds the incision, in addition to the development of cutaneous  vesicles  or bullae may be indicative of a deep SSI. [ 20 ]


Patients with complicated appendicitis (perforated appendicitis) are more likely to develop a SSI, abdominal abscess, or pelvic abscess during the post-operative period. Placement of an abdominal drain was originally thought to reduce the risk of these post-operative complications. However, abdominal drains have not been found to play a significant role in reducing SSIs and have led to increased length of stay in the hospital in addition to increased cost of the operation. [ 21 ]


About 327,000 appendectomies were performed during U.S. hospital stays in 2011, a rate of 10.5 procedures per 10,000 population. Appendectomies accounted for 2.1% of all operating-room procedures in 2011. [ 22 ]