Outcomes of Video-Assisted Thoracoscopic Wedge Resection Using a Non-Crushing Clamp and Continuous Sutures Plus Hemovac Drains Versus Staplers Plus Conventional Chest Tube: A Comparative Study

doi:10.21203/rs.3.rs-4095607/v1

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Outcomes of Video-Assisted Thoracoscopic Wedge Resection Using a Non-Crushing Clamp and Continuous Sutures Plus Hemovac Drains Versus Staplers Plus Conventional Chest Tube: A Comparative Study

https://doi.org/10.21203/rs.3.rs-4095607/v1

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OBJECTIVES.

In thoracoscopic surgery, we described wedge resection of the parenchyma with clamps and subsequent use of hemovac drains and compared it with the standard technique of using staplers and conventional chest tubes.

METHODS.

Fifty-nine patients who underwent thoracoscopic wedge resection between 2018 and 2024 were retrospectively analyzed. Patients were divided into two groups according to the surgical and drain types: stapler plus chest tube (S-ct, n = 27) and clamp plus hemovac drain (C-hd, n = 32). Air leak duration, postoperative drainage time, hospital stay duration, and total medical costs were also investigated.

RESULTS.

There were no significant differences in patient characteristics between both groups. The operation time was longer in Group C-hd (median 70 min versus median 60 min, p = 0.115). Prolonged air leak rates were similar between the two groups (11.1% and 12.5% in Groups S-ct and C-hd, respectively). The air leak duration and postoperative drainage time were not statistically significantly different between both groups (p = 0.872 and p = 0.176, respectively). The VAS scores on the first postoperative and day were significantly lower in Group C-hd (p = 0.02, and p = 0.02, respectively). Pain requiring additional treatment was significantly higher in Group S-ct (33.3% vs. 9.4%, p = 0.04). Total medical cost was statistically significantly higher in Group S-ct (median 371.7 vs. 191.6 dollars, p < 0.001).

CONCLUSION.

In thoracoscopic surgery, wedge resection of the parenchyma with clamping and subsequent use of a hemovac drain are comparable to the standard technique of using staplers and conventional chest tubes regarding short-term results and better economic results. Hemovac drainage can reduce postoperative pain.

VATS

wedge resection

Stapler

Chest tube

Hemovac

There has been a significant increase in the number of solitary pulmonary nodules and lung diseases requiring surgery due to lung cancer screening programs and easier access to the healthcare system [1–3]. Video-assisted thoracoscopic surgery (VATS), which results in less postoperative pain and shorter hospital stays, is widely used as an alternative to thoracotomy for lung diseases. For example, VATS lobectomy in patients with lung cancer has significantly increased to 50% in the last 15 years [4]. With the increased use of VATS, medical costs have increased, which is a particular problem especially in developing countries [5]. Therefore, some studies have described other methods such as energy devices, laser ablation, electrothermal tissue sealing systems, and endoscopic loop ligation instead of staplers [6–9].

Chest tubes, which can cause significant pain and discomfort and might be one of the main obstacles to enhanced recovery after surgery (ERAS), have been considered a proper drainage strategy after lung surgery for decades in universal clinical practice. However, they actually might be one of the main obstacles to ERAS [10]. In recent years, studies have been published in which drain types such as pigtail and pleural catheters were used instead of chest tubes [11]. Drainless surgeries are also being discussed to reduce pain and accelerate ERAS [12].

Because pulmonary wedge resection with VATS is expensive and conventional chest tubes cause pain, we examined patients who underwent wedge resection using a non-crushing clamp, absorbable sutures, and continuous sutures, and who underwent hemovac drain placement in the perioperative period. In the present study, we described wedge resection of the parenchyma with a clamp and subsequent use of a hemovac drain and aimed to compare it with the standard technique of using staplers and a conventional chest tube.

This study was approved by the Ethics Committee of Tekirdağ University of Medicine Faculty (No:2024.22.02.06). Written informed consent was obtained from all patients who underwent thoracic surgery.

The data of patients who underwent wedge resection with VATS for solitary or multiple peripheral pulmonary nodules and pulmonary disease at our institution were retrospectively analyzed. Patients diagnosed with primary lung cancer using frozen sections after wedge resection and subsequent anatomical lung resection were excluded from the study. This decision was made because the study aimed to specifically examine the outcomes of wedge resection performed using both clamps and staples, which could not be adequately assessed in this subgroup. Patients with significant concurrent illnesses or medical conditions, pulmonary bullae, or severe emphysema identified on chest CT were excluded because of potential complications. Patients with a history of oncologic treatment were excluded from the study because of the potential variability in treatment effects on the lungs. Patients who required conversion to thoracotomy for any reason were also excluded as they were outside the scope of the study.

Surgical procedures and grouping

Double-lumen tube intubation was routinely performed with the patient under general anesthesia, and the same anesthetic and pain control strategies were used for all patients. No local or epidural anesthesia preemptive techniques were used. Operations were performed by the same surgeon (Mithat Fazlıoğlu). Between the mid-and anterior axillary lines in the fourth (for pulmonary disease in the upper lobe) or fifth (for pulmonary disease in the middle and lower lobes) intercostal space, only one incision, a 4–5 cm width, was made. Uni-portal VATS was performed.

After exploring the parenchyma via thoracoscopy, which was introduced into the chest cavity, wedge resection was performed when an abnormal lung area was detected. If t a solitary pulmonary nodule or a pulmonary metastasis was detected after gently palpating the whole deflated lung parenchyma, it was resected. Wedge resection of the pulmonary parenchyma containing the lesion was then performed using a non-crushing clamp and continuous sutures with absorbable silk or staplers.

In wedge resection using a clamp, the clamp was closed slowly and the parenchymal lesion or disease was completely resected using a lancet. The lung parenchyma was then sutured using a U-shaped continuous running suture with 3 − 0 polyglactin sutures (Fig. 1a). When the suture was complete, the clamp was removed, and aerostasis was tested. A hemovac drain (12 Fr, 400 ml) was inserted through the same incision used for the VATS before suturing the wound layers (Fig. 1b). The collection chamber for the hemovac drain was connected to a vacuum source, usually a spring-loaded container or a mechanical pump. This negative pressure or suction helped draw fluid and air from the chest cavity into the drainage system during the postoperative period.

In the wedge resection performed using only a stapler, the parenchymal lesion or pulmonary disease was completely resected using an endoscopic linear cutter stapler. After aerostasis was tested, a conventional chest tube (24 Fr) was inserted through the same incision used for VATS before suturing the wound layers. The chest tube is connected to a single-chamber water-sealed bottle.

The patients were categorized into the stapler plus chest tube (S-ct) and clamping plus hemovac drain (C-hd) groups based on the type of wedge resection and the use of postoperative thoracic drains.

Although a chest tube was usually placed earlier in the study, later, it was gradually discovered that the hemovac drain could be used safely. Therefore, hemovac drains were frequently used during the last period of the study. It should also be noted that, before surgery, patients were informed in the surgical consent form about which type of drain would be used and whether wedge resection would be performed with a stapler or clamp.

Postoperative follow-up

Bedside chest radiography was performed in patients transferred to the ward at the postoperative third hour (Fig. 1c). On postoperative day one, the chest tube or hemovac drain was removed in patients with no pleural effusion or pneumothorax on the chest radiograph, no air leakage from the chest tube, and a drainage volume of < 150 ml / day. The patient was then discharged on the same day. Another chest radiograph was obtained one week later to determine whether the lung had expanded and pleural effusion had occurred.

When a fully expanded lung could not be observed on chest radiography following surgery, suction was applied to the chest tube or hemovac drain. In case of a non-expanded lung, the chest tube system was connected to negative suction, and if the patient had a hemovac drain, hemovac negative pressure suction was performed. Despite using suction, a chest tube was inserted in cases of non-expanded lungs seen on a chest radiograph. These patients were recorded as requiring reinsertion of a chest tube.

Prolonged air leak was defined as the presence of an air leak on day 7 after surgery. When air leak control was performed in patients with a hemovac drain, the free end of the cannula was placed in a cup of water and the patient was asked to cough. If air bubbled out of the cannula, an air leak was diagnosed. Patients who developed prolonged air leaks were discharged and followed-up in the outpatient clinic with a Heimlich valve on the 8th postoperative day. These patients were recorded as patients developed prolonged air leakages.

Pain control and assessment

Non-steroidal anti-inflammatory and analgesic drugs have been used for pain control in postoperative time. Paracetamol 1 gm over 15 min every 6 h and ketorolac 30 mg every 8 h were routinely administered to all patients. When patients complained of intolerable pain, an additional 50 mg tramadol was administered intravenously. The visual analog scale (VAS) score, which was explained to the patients the day before the operation, was used to define pain severity [13]. We used a traditional scale ranging from 0 to 10. Pain was assessed by a clinical nurse who was blinded to the study at the first hour, 24th, and 48th hours of the postoperative period. Sudden severe pain and pain requiring additional intervention were recorded.

Statistical analysis

The collected data were analyzed using Statistical Package for the Social Sciences (version 23.0; IBM Corp., Armonk, NY, USA). The normality of the distributions was determined using the Kolmogorov-Smirnov analysis. Data with normal distributions were reported as the mean (standard deviation, SD) and analyzed using Student's t-test. Pearson’s chi-square test was used to analyze qualitative variables, and Fisher's exact test was used when the sample size was small (less than 5 samples). Data with non-normal distributions were reported as median values and interquartile ranges (IQR). Nonparametric continuous variables were compared using the Mann–Whitney U test. Statistical significance was set at p < 0.05.

Between 2018 and 2024, 134 consecutive patients underwent wedge resection using VATS at our institution. Patients diagnosed with primary lung cancer through frozen section after wedge resection and subsequent anatomical lung resection (n = 40); patients with a serious concomitant illness, medical condition, pulmonary bullae, or severe emphysema identified on chest CT scans (n = 18); patients with a history of oncologic treatment (n = 10); and those who were converted from VATS to thoracotomy for any reason (n = 7) were excluded from the study. Based on these exclusion criteria, 59 patients were included in the study. Demographics, clinical characteristics, preoperative lung function, and radiological and surgical data of the patients are presented in Table 1. Complications developed in 12 patients (20.3%). The most common complication was prolonged air leakage (n = 7, 11.9%).

Table 1

Patients’ characteristics
Variables	Data (n = 59)
Age, year, median (IQR)	53 (34)
Sex, n/% Women Men	26/44.1 33/55.9
Cigarette used, n/%	41/69.5
Cigarette, pack/years, median (IQR)*	20 (20)
The presence of COPD, n/%	18 (30.5)
Diagnosis, n/% Pneumothorax Solitary pulmonary nodule Lung metastasis	25/42.4 21/35.6 13/22.0
FEV1, liter, mean ± SD	2.01 ± 1.01
FEV1, %, mean ± SD	81.6 ± 20.3
Wedge resection type, n/% Stapling and conventional chest tube Clamping and hemovac drain	27/45.8 32/54.2
The number of wedge resection, n/% 1 2	54/91.5 5/8.5
Operation time, minute, median (IQR)	70 (20)
Apply the postoperative suction, n/%	9/15.3
Complication, n/%	12/20.3
PAL prevalence, n/%	7/11.9
Space prevalence, n/%	5/8.5
Air leak duration time, day, median (IQR)	2 (1)
Drainage time, day, median (IQR)	2 (1)
Length of hospital stay, day, median (IQR)	4 (2)
Total cost of hospitalization, dollar, median (IQR)	208 (180)
* Calculated for the 41 patients who used cigarettes. SD, standard deviation; n, number; IQR, interquartile range; PAL, prolonged air leak; FEV1, Forced expiratory volume in the first second

The S-ct and C-hd groups included 27 and 32 patients, respectively. There were no significant differences in patient characteristics between both groups (Table 2). The operation time was longer in Group C-hd than in Group S-ct, although the difference was not statistically significant (p = 0.115).

Table 2

Comparison of the two groups in regards of the patients’ characteristics
Variables	Stapler plus chest tube (n = 27)	Clamp plus hemovac drain (n = 32)	p value
Age, year, median (IQR)	55 (34)	51.5 (37)	0.122
Sex, n/% Women Men	11/40.7 16/59.3	15/46.9 17/53.1	0.636
Cigarette used, n/%	20 / 74.1	21/65.6	0.483
Cigarette, pack/years, median (IQR)*	20 (30)	17 (23)	0.358
The presence of COPD, n/%	8/29.6	10/31.3	0.893
Diagnosis, n/% Pneumothorax Solitary pulmonary nodule Lung metastasis	15/55.6 6/22.2 6/22.2	10/31.3 7/21.9 15/46.9	0.103
Localization of wedge resection, n/% Upper lobe Middle lobe Lower lobe	15/55.6 3/11.1 9/33.3	18/56.2 3/9.3 11/34.3	0.897
FEV1, liter, mean ± SD	2.08 ± 0.72	2.13 ± 1.06	0.404
FEV1, %, mean ± SD	80.5 ± 21.6	82.4 ± 19.7	0.777
The number of wedge resection, n/% 1 2	24/88.9 3/11.1	30/93.8 2/6.2	0.652
Operation time, minute, median (IQR)	60 (15)	70 (20)	0.115
* Calculated for the 41 patients who used cigarettes. SD, standard deviation; n, number; IQR, interquartile range; FEV1;Forced expiratory volume in one second

The prolonged air leak rate was 11.1% (n = 3) and 12.5% (n = 4) in Groups S-ct and C-hd (p = 1.000), respectively. The application of postoperative suction was comparable between both groups (p = 1.000). The total air leak duration and postoperative drainage time were not statistically significantly different between both groups (p = 0.176 and p = 0.981, respectively). The total medical cost of hospitalization was statistically significantly higher in Group S-ct than Group C-hd (median 371 dollars versus median 191 dollars, p < 0.001) (Table 3). Chest tube reinsertion was needed for two patients in Group S-ct (for severe air leakage and residual pleural space) and two patients in Group C-hd (for pleural effusion that could not be drained with a hemovac drain) (p = 1.000).

Table 3

Comparison of the two groups in regards of the postoperative follow-up
Variables	Stapler plus chest tube (n = 27)	Clamp plus hemovac drain (n = 32)	p value
Apply the postoperative suction, n/%	4/14.8	5/15.6	1.000
Complication, n/%	6/22.2	6/18.8	0.741
PAL prevalence, n/%	3/11.1	4/12.5	1.000
Space prevalence, n/%	2/7.4	2/9.4	1.000
Air leak duration time, day, median (IQR)	2 (1)	2 (1)	0.872
Drainage time, day, median (IQR)	3 (2)	2 (2)	0.176
Chest tube reinsertion, n/%	2/7.4	2/6.3	1.000
Length of hospital stay, day, median (IQR)	4 (2)	4 (2)	0.981
Re-admission within one month after discharge, n/%	0	0	na
Total cost of hospitalization, dollar, median (IQR)	371	191	< 0.001
n, number; IQR, interquartile range; FEV1; Forced expiratory volume in one second; na, not applicable. Bold p values indicate statistical significance.

The prevalence of sudden severe pain was higher in Group S-ct than in Group C-hd (25.9% vs. 9.4%, respectively), although the difference was not significant (p = 0.09). Pain requiring additional treatment was significantly higher in Group S-ct than in Group C-hd (33.3% vs. 9.4%, p = 0.04). In the postoperative period, the VAS in the first hour and first postoperative day was significantly lower in Group C-hd (2.46 ± 1.31 versus 3.44 ± 1.73, p = 0.02, 2.15 ± 0.98 versus 2.74 ± 1.19, p = 0.02, respectively). The VAS on postoperative day 2 was also lower in Group C-hd (1.81 ± 0.85 versus 2.07 ± 0.67), although this difference was not statistically significant (p = 0.09) (Fig. 2) (Table 4).

Table 4

Pain and VAS outcomes
	Stapler plus chest tube (n = 27)	Clamp plus hemovac drain (n = 32)	p value
Sudden severe pain, n/%	7/25.9	3/9.4	0.09
Pain required additional treatment, n/%	9/33.3	3/9.4	0.02
Postoperative 1st hour VAS, mean (SD)	3.44 ± 1.73	2.46 ± 1.31	0.02
Postoperative day 1 VAS, mean (SD)	2.74 ± 1.19	2.15 ± 0.98	0.02
Postoperative day 1 VAS, mean (SD)	2.07 ± 0.67	1.81 ± 0.85	0.09
VAS, visual analog scale; SD, standard deviation; n, number. Bold p-values indicate statistical significance.

The current clinical environment shows a strong trend supporting VATS that uses staplers to resect the parenchyma in various thoracic surgeries [4]. However, this process is expensive [5–7]. Additionally, contemporary endoscopic linear cutting staplers include at least 3.8 mm titanium staples in two double rows. These staplers cut and divide the tissue between two double rows simultaneously. However, this results in at least three rows of staples along the edge of the specimen, making it difficult for pathologists to accurately determine the boundaries for microscopic examination. The actual margins of the specimen need to be discarded before microscopic examination by a pathologist [14]. Moreover, stapling along the lung parenchyma can lead to tissue granulation, which can be confused with recurrence [15]. Therefore, preserving the surgical margin is a significant concern and the use of surgical equipment should be carefully planned. Despite certain limitations, wedge resection with a clamp can overcome these challenges. To the best of our knowledge, no study has been published thus far on the clamping and primary suturing technique, which is the cheapest type of wedge resection and was frequently used in thoracotomy in the period before the stapler was used in thoracoscopic surgery. In the present study, which included two groups with no statistically significant differences in sex, age, lung function (FEV1), presence of COPD, reason for surgery, and number of concurrent wedge resections, there were no differences in short-term outcomes such as prolonged air leakage or the need for a second drainage method between patients undergoing wedge resection with a clamp and those undergoing stapler application.

The operation time was longer in Group C-hd than in Group S-ct, likely due to the application of surgical suturing, which requires more time than using a stapler. It should also be noted that wedge resection with a clamp may not be applicable in all patients. Performing wedge resection with a non-crush clamp can be challenging in cases where the nodule is deep, there is extensive disruption of the visceral pleura and parenchyma in patients with pneumothorax, the base of the bulla is wide in patients with bullae, or when there are multiple metastatic nodules in different lobes. Our analyses further revealed lower total in-hospital expenditure in the C-hd group than in the S-ct group. This suggests that the policy of performing wedge resection with a clamp may have financial benefits for selected patients. In our country, the low bed costs compared to other countries and the fact that public insurance covers package fees for surgeries have resulted in an average cost difference of only $180 between the two groups. If a study similar to ours was conducted in countries where disposable surgical instruments are more expensive, the cost difference would certainly be higher. Cost-effectiveness should never compromise the highest priority, which is postoperative safety. In situations where patient safety is at risk, the use of an endoscopic stapler is crucial.

In contrast, drainage systems specifically designed for thoracic surgery, such as chest tubes, can cause more pain, longer drainage periods, and greater amounts of drainage fluid [10, 12, 16]. Hemovac drains are primarily designed for use in general surgery, orthopedic surgery, and plastic surgery to remove fluids (such as blood or serous fluid) from the surgical site [17]. Hemovac drains, made of flexible, soft, and pliable plastic with a one-way valve mechanism that allows fluid collection while preventing the backflow of air and fluid into the patient, can mitigate these issues. The vacuum effect in hemovac drains is created by the negative pressure within the drainage system, which may facilitate the removal of air from the chest cavity. There has been no study compared to the effectiveness of the conventional chest tubes and hemovac drains in patients undergoing wedge resection with VATS. In the present study, no significant differences were observed in the complications, drainage duration, or residual parenchymal space between the hemovac drain and conventional chest tube groups. Despite having a smaller diameter tube and a lower flow rate, hemovac drains did not significantly affect the total volume of fluid or air to be drained over a relatively extended period. In a recent prospective randomized study comparing pigtail catheters and chest tubes, the application of a drain with a smaller diameter, such as a pigtail, instead of a chest tube, did not pose problems in terms of drainage efficacy or perioperative safety [10]. In a prospective, single-center, randomized study, comparing the use of a 2-lumen central venous catheter (7 Fr × 20 cm) with a 20–24 Fr chest tube in patients undergoing wedge resection, no significant differences were observed between the two groups in terms of postoperative pneumothorax, pleural effusion, or the need for chest tube reinsertion [18]. Furthermore, patients in the group where a 2-lumen central venous catheter was applied tended to have significantly shorter hospital stays than those with chest tube application. These findings contradict the belief that narrower catheters, such as the hemovac drain, may lead to insufficient fluid or air drainage.

Upon awakening after lung surgery, patients commonly experience primary complaints of chest pain attributed to the presence of a chest tube [19]. It has been suggested that the use of smaller chest tubes may result in less postoperative pain compared to larger tubes [20]. A recent study comparing the use of a pigtail catheter with a chest tube in patients undergoing VATS showed that the drainage strategy was the sole factor influencing the frequency of intervention-requiring pain [10]. A prospective study examining VATS lobectomies using a Foley catheter or a 28F chest tube demonstrated that the Foley catheter caused significantly less pain than the chest tube [21]. In another study comparing the use of an air extraction catheter with a chest tube in patients undergoing pulmonary wedge resection, patients in the catheter group had significantly lower pain scores than those in the chest tube group [18]. We observed that pain during the first postoperative hour and on the first postoperative day was significantly lower in the C-hd group than in the S-ct group. In addition, pain requiring additional treatment was significantly higher in patients who underwent chest tube placement than in those who underwent hemovac drain placement. Hemovac drains, made of soft and pliable plastic, result in less pain for the patient, both during insertion and while the tube is in place. This circumstance may contribute to earlier ambulation and permit a longer duration of physical exercise during the initial postoperative period. It should be noted that rapid recovery should never compromise the foremost priority, which is postoperative safety. When patient safety is jeopardized, implementation of intraoperative chest drainage becomes imperative. Despite the limited number of documented cases, existing literature supports the safety of employing hemovac drainage instead of traditional chest tubes. Nonetheless, the outcomes associated with post-surgery hemovac drainage remain uncertain.

First, this was a retrospective study. It is clear that such studies should be conducted prospectively. Due to the retrospective nature of the study, bias in patient selection among the groups could not be eliminated. Second, we selected patients who did not have severe emphysema or parenchymal disease, and who underwent VATS pulmonary wedge resection. In cases of visceral pleural air leakage in the perioperative period, pleural adhesions, or existing emphysema, using a stapler instead of a clamp may be a more accurate option. In addition, the use of chest tubes is crucial in such patients. Third, it should be noted that pain assessed by the VAS is not an objective measure. Moreover, in the present study, the impact of the pain caused by the passage of the stapler arm through the intercostal space during wedge resection, performed with the assistance of a stapler, on postoperative pain has not been quantified.

Surgeons can choose soft, pliable tubes such as hemovac drains, which are sufficiently large to prevent clotting and likely to result in less pain. In selected patient groups, the utilization of the hemovac drain method demonstrated outcomes comparable to those of the traditional chest tube method. Moreover, it reduces pain and is potentially more cost-effective. The approach outlined in this study, involving wedge resection with a clamp and a hemovac drain, may be deemed a safe procedure that can enhance patient recovery and alleviate postoperative pain following VATS pulmonary wedge resection. However, multicenter, prospective, double-blind studies are needed to further investigate this issue.

C-hd: clamping plus hemovac drain group

ERAS: enhanced recovery after surgery

IQR; interquartile range

PAL; prolonged air leak;

SD: standard deviation

S-ct: Stapler plus chest tube group

VAS: The Visual Analogue Scale

VATS: Video-assisted thoracoscopic surgery

Conflict of interest:

The authors declare no conflicts of interest.

Funding:

The author received no financial support for this research or its authorship.

Author Contribution

Author Contributions: Idea/concept: M.F., Design: M.F., Control/supervision: M.F., Data collection and/or processing: M.F., Analysis and/or interpretation: M.F., Literature review: M.F., Writing the article: M.F., Critical review: M.F., References and fundings: M.F., Fundings materials: M.F.

Data Availability Statement:

The data presented in this article cannot be shared publicly to ensure privacy of the individuals who participated in the study. However, the data were shared upon reasonable request from the corresponding authors.

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No competing interests reported.

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Outcomes of Video-Assisted Thoracoscopic Wedge Resection Using a Non-Crushing Clamp and Continuous Sutures Plus Hemovac Drains Versus Staplers Plus Conventional Chest Tube: A Comparative Study

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Abstract

OBJECTIVES.

METHODS.

RESULTS.

CONCLUSION.

Figures

INTRODUCTION

PATIENTS and METHODS

Surgical procedures and grouping

Postoperative follow-up

Pain control and assessment

Statistical analysis

RESULTS

DISCUSSION

Limitations

Conclusion

Abbreviations

Declarations

Conflict of interest:

Funding:

Author Contribution

Data Availability Statement:

References

Additional Declarations

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