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At least 415 records · Page 23Linked to original sources
PubMed1993

Prospective randomized study of routine intraoperative cholangiography during open cholecystectomy: long-term follow-up and multivariate analysis of predictors of choledocholithiasis.

A prospective randomized study was performed to assess the value of routine intraoperative cholangiography (IOC) during cholecystectomy for gallstone disease. Four hundred and fifty-seven consecutive patients were screened for the presence of 11 predefined clinical criteria assumed to indicate choledocholithiasis. Two hundred and eighty patients who had no positive criteria and in whom preoperative endoscopic retrograde cholangiography had not been performed were randomized at the operating table to the IOC or no-IOC group. Follow-up was performed 6 to 8 years after the operation with a questionnaire and by use of clinical, biochemical, and radiologic investigations as indicated. Multivariate analysis was used to identify independent predictors of choledocholithiasis and the combination of criteria having the best predictive ability. The frequency of common bile duct calculi at operation was significantly correlated with age and with all clinical criteria except recent or present pancreatitis. However, only serum bilirubin level, cystic duct diameter, demonstration of common bile duct calculi on preoperative imaging or intraoperative palpation, and age at operation were independent predictors of choledocholithiasis. The overall best subset of clinical indicators contained all criteria with the exception of pancreatitis and alkaline phosphatase level. Negative predictive ability of the set of criteria was 100% for patients up to 60 years of age and 97% for patients older than 60 years at the time of operation. No case of residual common bile duct calculi was present in the IOC and no-IOC groups at follow-up. Our data strongly support a policy of performing IOC during cholecystectomy only when clinical criteria suggest the presence of common bile duct abnormalities or to clarify ductal anatomy.

Biliary Tract↗
PubMed2000

Sample size tables for receiver operating characteristic studies.

OBJECTIVE: I provide researchers with tables of sample size for multiobserver receiver operating characteristic (ROC) studies that compare the diagnostic accuracies of two imaging techniques. MATERIALS AND METHODS: I computed the number of patients and observers needed as a function of five parameters: the measure of diagnostic accuracy (area under the ROC curve, sensitivity at a false-positive rate </= 0.10, or specificity at a false-negative rate </= 0.10), conjectured level of accuracy, suspected difference in accuracy between the two imaging techniques, observer variability, and ratio of patients without to patients with the condition. RESULTS: The numbers of patients and observers required vary dramatically with these five parameters, increasing with more refined measures of accuracy, with lower accuracy levels, with smaller suspected differences, with greater observer variability, and with less balanced designs. The number of patients required for a study can be reduced by increasing the number of observers, and vice versa. When the intra- and interobserver variability is large, a study design with just four observers is usually inadequate. CONCLUSION: Many factors must be considered when determining the appropriate sample sizes for multiobserver ROC studies. My tables serve only as initial ballpark estimates. Investigators should compute sample size using parameters that reflect their clinical application.

ROC Curve↗
PubMed2005

Laparoscopic adrenalectomy in pheochromocytomas.

BACKGROUND: The aim of this study was to evaluate 17 patients undergoing laparoscopic adrenalectomy for the treatment of pheochromocytoma by transperitoneal anterior approach. METHODS: Seventeen patients underwent laparoscopic adrenalectomy for pheochromocytoma between January 1994 and May 2002. Ten females (58.8%) and 7 males (41.2%) were operated on; 14 patients (82.3%) had sporadic pheochromocytoma and 3 (17.7%) were familiar cases. Mean age was 42 yr (range 25-72 yr). All patients were treated pre-operatively with alpha-blockers. Seven patients (41.2%) underwent right adrenalectomy; 9 (52.9%) underwent left adrenalectomy and 1 (5.9%) bilateral adrenalectomy. RESULTS: No conversion to open surgery occurred and no mortality was observed. The right-side adrenalectomy required a mean operative time of 86 min (range 45-120), the left-side procedure a mean operative time of 116 min (range 80-140) and the bilateral one 219 min. In two patients (11.8%), a laparoscopic cholecystectomy and ovariectomy, respectively, were performed without changing the position of the patient on the operating table. Only 1 patient (5.9%) presented significant intraoperative hypertension, and arrhythmia resolved by medical therapy. No other intraoperative and post-operative complications were reported. Mean hospital stay was 3 days (range 2-8 days). At mean follow-up of 48 months (range 6-96 months), regression of symptoms and control of blood pressure were obtained without additional treatment in all patients. No recurrences were reported. CONCLUSION: In our experience, adrenal pheochromocytoma can be treated safely and effectively by laparoscopic transperitoneal anterior approach.

Adrenal Gland Neoplasms↗
PubMed1981

New self-retaining retractor holder to facilitate surgical exposure.

A new self-retaining retractor holder has been developed which is so simple in design that no additional expensive, cumbersome or complicated equipment is needed. It invaginates the sterile draping to hook onto a standard ether screen in any position desired. It holds most standard retractors and can be quickly applied, repositioned or removed without breaking sterility. It will provide simultaneous forceful and gentle retraction. It is extremely versatile. An extra ether screen appropriately applied to the operating table will provide support for multidirectional cervical, thoracic, abdominal or perineal exposure. The retractor holder greatly reduces the need for extra operating room personnel.

Surgical Equipment↗
PubMed1988

Analysis of 18 recent cases of penetrating injuries to the common and internal carotid arteries.

Penetrating injuries to the common and internal carotid artery carry the unique potential for irreversible neurologic damage, respiratory collapse, and exsanguination. This study analyzes a recent 4 year experience with 18 cases of penetrating injury to the carotid artery to identify the factors influencing surgical decision-making, perioperative complications, and mortality. Sixteen patients with acute respiratory distress required emergent airway intubation. Three patients in hemorrhagic shock were brought directly to the operating room; the remaining 15 underwent emergency carotid arteriography. Three patients with multiple intramediastinal vascular injuries exsanguinated on the operating table before hemorrhage could be controlled. There were no deaths or neurologic complications in the 14 surviving patients who had an operation on the carotid artery, including 2 patients treated by internal carotid artery ligation. Early control of the airway was the most common initial requirement in this group of patients. Judicious use of preoperative arteriography was thought to facilitate the operative approach in selected patients. A flexible surgical approach to the damaged carotid artery is essential based on the patient's hemodynamic status, degree of neurologic impairment, and nature and extent of arterial damage.

Adolescent↗
PubMedDate not supplied

Noncontact electrosurgical grounding is useful in burn surgery.

Grounding patients with large burns to facilitate the use of electrocautery devices during surgery is commonly difficult because of the paucity of available grounding sites. The Mega 2000 Patient Return Electrode System (Megadyne Medical Products, Draper, UT) is an electrode designed to provide electrical return to facilitate function of electrocautery devices without direct patient contact. It accomplishes this by having a very large surface area (720 square inches) in the form of a reusable pad placed on the operating table that is covered by an impermeable drape and clean sheet beneath the patient. We used this noncontact device in 25 operations of 17 children with large burns and limited availability of traditional grounding sites. The patients had an average age of 8.8 + 4.6 years (range, 14 months-14 years), average burn size of 55 + 33% of the body surface (range, 10-95%), and average weight of 33.0 + 17.9 kg (range, 9-75 kg). Operations included 22 excision and grafting operations, an axillary release, a neck release, and bilateral groin releases. The device functioned well in all cases. There were no cutaneous burns observed. No additional traditional devices required placement. We found the device useful in burn surgery in those cases where there is a paucity of traditional grounding sites available.

Adolescent↗
PubMedDate not supplied

Pressure sore formation in the operating theatre: 1.

While theatre nurses strive to master increasingly sophisticated equipment and techniques they must also endeavour to ensure that the quality of fundamental nursing care has positive outcomes for the patient. According to Land (1995), pressure area care is such a fundamental nursing activity that many health professionals do not recognize the importance of keeping abreast of new developments. A review of the literature concerning pressure sore formation suggests that, far from being a ward-based problem, all surgical patients experience a critical period during which they are most susceptible to pressure injury--the time spent on the operating table. This article, the first of two parts, outlines the pathophysiology of pressure sores and the contributory factors present within the operating theatre. The second part suggests nursing interventions to reduce the incidence of pressure sore formation during the perioperative phase.

Humans↗
PubMed1985

Conservation of hearing in acoustic schwannoma surgery.

Hearing conservation in acoustic schwannoma surgery is possible in approximately 50% of patients those tumors measure 15 mm or less in size (medial to the porus acusticus) and whose speech discrimination score in the ear with the tumor is 80% or better. The concepts of total tumor removal and maximum sparing of adjacent normal neural tissue are consistent with efforts to retain cochlear function. A retrosigmoid approach is favored over the middle cranial fossa approach because of its superior exposure and less morbidity. An operating table capable of 35 degrees side rotation is used because it allows the majority of patients with acoustic neuromas to be operated on in the horizontal supine position. The posterior lip of the internal auditory canal is removed to within approximately 1.5 mm of the falciform crest. Tumors not extending to the fundus afford an ideal situation for total removal, early identification of the seventh cranial nerve, and preservation of hearing. The carbon dioxide laser is a useful surgical tool with its properties of vaporization, cutting, and coagulation.

Carbon Dioxide↗
PubMed1995

[Total intravenous anesthesia (TIVA) in geriatric surgery. S-(+)-ketamine versus alfentanil].

In this prospective, randomized study, two regimens of total intravenous anaesthesia (TIVA), with propofol and S(+)-ketamine (S-ketamine) and with propofol and alfentanil, were compared with reference to endocrine stress response, circulatory effects and recovery. METHODS. The investigation was conducted in two groups of 20 ASA I-III patients over 60 years of age who were scheduled for endoprothetic orthopaedic surgery. After oral premedication with midazolam, patients received a TIVA with body-weight-adjusted doses of propofol, and S-ketamine or alfentanil as the analgesic component. For CPPV (PEEP 5 mbar), air and oxygen (FiO2 33%) were used. For muscle relaxation, patients of both groups received vecuronium in body-weight-adjusted doses. Blood samples were taken through a central venous line at seven time points before induction of anaesthesia and on the first morning after the operation also for analysis of epinephrine, norepinephrine (by HPLC/ECD), and ADH, ACTH and cortisol (by RIA). In addition, SAP, HR, arterial oxygen saturation, recovery from anaesthesia and side effects were observed. RESULTS. The two groups had comparable group mean values for age (S-ketamine group 71 years, alfentanil-group 70 years), other biometric data, and duration of anaesthesia and operation (Table 1). Plasma levels of epinephrine, norepinephrine (Table 2, Fig. 1), ADH (Table 2, Fig. 2) ACTH and cortisol (Table 2, Fig. 3) were higher in the S-ketamine-group (P < 0.05) owing to the intraoperative course of these endocrine parameters. Before induction, and on the first morning after the operation, levels were comparable between the groups. 5 min after the induction of anaesthesia, SAP and HR (Table 3) were significantly lower in the alfentanilgroup (P = 0.001). Recovery from anaesthesia (orientation with respect to person and location) was faster in the alfentanilgroup (16 vs 39 min, P = 0.001). An arterial oxygen saturation below 90% was observed in 7 patients in the S-ketamine- and 13 patients in the alfentanilgroup (P = 0.03). Four patients with S-ketamine reported dreams, and 1 dream was judged negative. Postoperative emesis was found in 6 patients in the S-ketaminegroup and 12 patients in the alfentanilgroup (P = 0.03). All patients said they would agree to undergo the same anaesthetic technique again. CONCLUSIONS. Considerable differences were found in the endocrine stress response of the two groups. With respect to endocrine response and circulation, TIVA with propofol and S-ketamine had sympathomimetic properties with positive circulatory effects and led to moderate endocrine stimulation. This should be kept in mind in patients with hypotension, hypothyrosis, or adrenocortical insufficiency; because "eustress" might be beneficial in this group of patients. On the other hand, TIVA with propofol and alfentanil showed sympatholytic properties, with negative circulatory effects and a remarkable reduction of endocrine stress response. This might be beneficial in patients with hypertension and states of endocrine hyperfunction. Both regimens were accompanied by such typical side effects as dreams, delayed recovery, reduced ventilation, and emesis, which should also be considered.

Aged↗
PubMed2005

Development of the needle insertion robot for percutaneous vertebroplasty.

Percutaneous Vertebroplasty (PVP) is an effective and less invasive medical treatment for vertebral osteoporotic compression fractures. However, this operative procedure is quite difficult because an arcus vertebra, which is narrow, is needled with accuracy, and an operator's hand is exposed to X-ray continuously. We have developed a needle insertion robot for Percutaneous Vertebroplasty. Its experimental evaluation on the basic performance of the system and needle insertion accuracy are presented. A needle insertion robot is developed for PVP. This robot can puncture with accuracy and an operator does not need to be exposed to X-ray. The mechanism of the robot is compact in size (350 mm x D 400 mm x H270 mm, weight: 15 kg) so that the robot system can be inserted in the space between C-arm and the patient on the operating table. The robot system is controlled by the surgical navigation system where the appropriate needle trajectory is planned based on pre-operative three-dimensional CT images. The needle holding part of the robot is X-ray lucent so that the needle insertion process can be monitored by fluoroscopy. The position of the needle during insertion process can be continuously monitored. In vitro evaluation of the system showed that average position and orientation errors were less than 1.0 mm and 1.0 degree respectively. Experimental results showed that the safety mechanism called mechanical fuse released the needle holding disk properly when excessive force was applied to the needle. These experimental results demonstrated that the developed system has the satisfactory basic performance as needle insertion robot for PVP.

Bone Cements↗
PubMed2005

On-table diagnostic accuracy and the clinical significance of routine exploration in open appendectomies.

INTRODUCTION: The current practice of further exploration for other intra-abdominal pathology only when a normal appendix is found may leave other organic causes of acute abdomen undetected if the surgeon's on-table diagnostic accuracy is low. METHODS: In this retrospective study in 518 patients who underwent surgery for acute appendicitis, the on-table operative diagnosis of surgeons was correlated with the histological diagnosis of pathologists. RESULTS: Surgeons were unable to make an accurate on-table diagnosis in 14.3% of cases. The sensitivity for diagnosing normal appendices was also low at 51.3%, suggesting that almost half of normal appendices were misdiagnosed as acute appendicitis and there was no further exploration for other pathology. It was also found that surgeon's experience, patient gender and patient age had no significant effect on diagnostic accuracy. CONCLUSION: Based on these results, it seems that the on-table diagnostic accuracy in open appendectomies is low and surgeons' on-table diagnosis should not be the determining factor for whether further exploration is necessary. Exploration for other intra-abdominal pathology should be routine irrespective of the on-table diagnosis, the surgeon's experience and patient gender and age. An alternative is minimal-access surgery in which inspection of other intra-abdominal organs can be performed more easily.

Adolescent↗
PubMed1993

Laparoscopic Nissen fundoplication.

A technique for laparoscopic Nissen fundoplication is described and a series of 11 cases is presented. The technique secures the patient to the operating table with three safety straps and the patient is then placed in a reverse Trendelenburg position with the hips flexed. The surgeon operates from the patient's right side using two midline trocar sites as the main operating ports. Other ports provide retraction and laparoscope access. The liver retractor is held by a mechanical arm. Once the esophageal peritoneum has been opened, the esophagus and diaphragmatic crura are dissected out and elevated by a Penrose drain sling. The short gastrics are divided and the fundus is brought posterior to the esophagus passing from left to right. A large Maloney dilator is placed in the esophagus and the fundal wrap is sutured to the anterior aspect of the stomach by three sutures; the inferior--most of which incorporates the anterior wall of the esophagus. Once the fundoplication is completed, the dilator is replaced by a nasogastric tube. Postoperatively, patients are given clear liquids and when these are tolerated the nasogastric tube is removed. Most patients are discharged on the second or third postoperative day. Operating time averaged 147 min, and all patients returned to unrestricted activity within 2 to 3 weeks. All patients reported complete relief of gastroesophageal reflux. Average follow up was 120 days with a median of 148 days. Long-term follow up is in progress.

Adult↗
PubMed2002

[Video-assisted myocardial revascularization and left-sided minithoracotomy using the Symmetry automatic connector].

OBJECTIVE: Introduction of the new method of videoassisted multiple direct revascularization of the heart muscle from left-sided minithoracotomy (LAST--Left Anterior Small Thoracotomy) using an automatic connector of central anastomoses Symmetry (St. Jude Medical ATG, Inc., St. Paul, MN) in patients indicated for re-operation of bypasses of the coronary arteries or with pathological conditions of the sternum and for the cosmetic effect of submammary incisions in women. METHOD: From September 2001 to the end of February 2002 15 patients with affections of three arteries had an operation from a LAST approach with videoscopic construction of central anastomoses by means of a Symmetry connector with portal entries and the use of extracorporeal circulation introduced from the groin without cardioplegic arrest. Nine men and six women were operated with a mean age of 68.7 years and a mean ejection fraction (EF) of 58.2%. In seven instances reoperation of aortocoronary bypasses was involved; two patients with multiple myelomas (morbus Kahler) had a brittle and cavernously altered sternum, all six women wanted a small skin incision below the breast. The criterion for ruling out the mentioned procedure was marked atherosclerotic affection of the ascendent aorta, affection of the arteries in the aortoiliac area and affection of one or two coronary arteries suitable for miniinvasive revascularization without extracorporeal circulation. Fourteen patients had an angiographic check up examination of the patency of grafts before they were discharged. RESULTS: The total number of distal anastomoses per patient was 3.13 +/- 0.6, the median period of extracorporeal circulation was 112 +/- 34 minutes and the mean time of operation 186 +/- 52 minutes. Blood losses were on average 425 ml/24 h without necessity of revision on account of haemorrhage. Eleven (73%) patients were subjected to an ultra fast track protocol with extubation on the operating table. The mean time spent in the postoperative department was 8.6 hours and the total hospitalization period 5.5 days. None of the operated patients died. Peroperative ischaemia of the heart muscle was not observed, in one instance the authors observed a newly developed atrial fibrillation. During an angiographic check-up the authors detected 6 (13.6%) stenoses and occlusions in 44 checked bridged vessels. CONCLUSION: The alternative approach reduces the risk of cardiac injury during reoperation and the danger of impaired healing of the sternotomical wound in patients with pathological conditions of the sternum, with contamination of the surrounding tissue (e.g. in tracheostomy) or malignant disease. The cosmetic effect of the submammary incision, the small inguinal incision and endoscopic saphenous vein harvesting should be considered in elective direct revascularization of the heart muscle in women. Bridging of the coronary arteries with optical assistance from minithoracotomy and with an automatic connector of central anastomoses seems to be a safe alternative of standard sternotomy only with methodological but not anatomical or functional restriction.

Aged↗
PubMed1998

Transport of surgically produced aerosols in an operating room.

The particle transport characteristics of two ventilation configurations commonly used in hospital operating rooms (ORs), cross-flow and impinging-flow ventilation, were investigated. The computational fluid dynamics software FLUENT was used to simulate turbulent airflow with mixed convection in a three-dimensional, rectangular OR. Two OR personnel, a patient, OR spotlights, an anesthetics cart, and an operating table were represented in the room. Heat loads from the personnel, patient, and lights affected the airflow through buoyancy. Particles produced at the operation site with various sizes and initial conditions were tracked through the room. A stochastic model was used to include the random effects of turbulence on particle trajectories. Simulation results show that heat loads from the personnel, patient, and OR spotlights had an important effect on the airflow through natural convection. Particle trajectories were influenced greatly by the flow field structure, particle launch position, and turbulence in the flow, and somewhat by particle size. However, particle paths were insensitive to the launch velocity. Virtually identical trajectories were obtained for particles with launch velocities ranging from 0 to 1 m/sec in magnitude. Changes in ventilation configuration dramatically affected particle transport. The cross-flow ventilation configuration performed better, based on the criteria of removing particles from the breathing zone of room occupants. Proper flow field design and contaminant source placement can be used to control particle transport. Numerical simulations allow quick and inexpensive comparisons between room designs and provide details about airflow and contaminant transport.

Aerosols↗
PubMed1975

Surgical treatment of hydatid cysts of the central nervous system in the pediatric age (Dowling's technique).

Single hydatid cysts of the brain are rarely seen by pediatric neurosurgeons who do not reside in certain countries, i.e. Australia, Uruguay, and Argentina. It is, however, of considerable importance that every pediatric neurosurgeon be aware of the manner of diagnosis of this condition and surgical management of these patients. Out of 35 cases of hydatidosis of the CNS and its covering observed over a 42-year period, there were 29 hydatid cysts of the brain and one of the spinal cord. Emphasis is placed on the former. Surgically, the hydatid cyst can be removed intact. The essential steps of the technique are: (1) a large flap; (2) careful handing during all the operative steps avoiding monopolar coagulation; (3) opening of the atrophic cortex overlying the cyst over an area whose diameter should be no less than three quarters of the diameter of the cyst, and (4) letting the cyst come out by just lowering the head of the operating table and instillating warm saline between the cyst and surrounding brain. In this series of hydatid cysts of the CNS, there was no operative mortality. The 20 cases in which the cyst was removed unbroken with Dowling's technique are alive and only two have sequelae of the preoperative lesion (blind). In the 11 cases in which Dowling's technique was not used and the cyst broke during ventriculography (3) or surgery (7, one broke spontaneously), only 7 are alive and well and there were 4 late deaths.

Adolescent↗
PubMed1989

Atrial myxomas: results of 25 years' experience and review of the literature.

Twenty patients with atrial myxoma from a 25-year period were reviewed. Sixteen patients had a tumor in the left atrium, three in the right, and one had a biatrial myxoma. The main clinical presentations were dyspnea and tachyarrhythmias seen in 11 patients. Nineteen patients had a correct preoperative diagnosis. Echocardiography confirmed the diagnosis in eight patients, angiocardiography in four, and both these techniques in seven. The diagnosis was established at the operative table in one case in which the preoperative diagnosis was mitral stenosis. All tumors were successfully removed with cardiopulmonary bypass. There were no operative deaths. Excision of the tumor resulted in marked symptomatic improvement. No recurrences have been observed. A differential approach to preoperative investigation, surgical treatment, and follow-up is suggested according to the clinical behavior of the tumor. Excision of the tumor appears to be curative, with no recurrences at long-term follow-up in cases of "sporadic" myxoma. The risk of recurrences is much higher when a "complex" or a "familial" myxoma is faced. For these types, our recommendations are presented.

Adult↗
PubMed2004

[Mammaplasty: the "love position"].

The authors describe a new position of the patient that enables the surgeon to perform a bilateral and synchronous mammaplasty, without switching sides. The patient is first raised in the sitting position, then the thigh and leg holders of the operating table are spread out to a 45-60 degrees angle. The surgeon stands in between the thighs, where he faces the chest and can operate on the breasts. The entire operation is performed by the surgeon, approaching both breasts simultaneously without the need for switching positions. The direct and central access, along with the continuing visual control of the shaping, turns the operation into a simple and faster one with better control of the cosmetic result.

Female↗
PubMedDate not supplied

Prevention of rhabdomyolysis in bariatric surgery.

BACKGROUND: Rhabdomyolysis (RML) is a clinical and biochemical syndrome caused by skeletal muscle necrosis that results in extravasation of toxic intracellular contents from the myocytes into the circulatory system. Postoperative RML in bariatric surgery occurs with various non-physiological surgical positions, with prolonged muscle compression. The potential consequences may lead to death. The purpose of this study is to review its pathophysiology and the best ways to prevent RML in bariatric surgery. METHODS: We searched the literature and reviewed all relevant articles, by searching for the keywords: rhabdomyolysis, morbid obesity, prevention and bariatric surgery, giving a total of 39 articles. RESULTS: Prevention may be enhanced by careful padding on the operative table at all pressure-points. Changing patient position, both intraoperatively and postoperatively, also reduces RML. A potential new solution to decrease the longer operative time and avoid RML is to perform the bariatric operation in two stages. Another way to limit the duration of surgery in high-risk patients is to alert surgeons not to select super-obese high-risk patients early in the learning curve. CONCLUSION: As RML is an important and potentially fatal complication of bariatric surgery, the best way to avoid it is effective prevention. More research on this subject is necessary.

Acute Kidney Injury↗