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The operating room has become a hotbed for hospital technology. Headset-wearing surgeons issue voice commands to adjust lighting, reposition cameras and raise or lower the operating table. Surgical robots on wheels move from one OR to the next. Decision-support tools alert clinicians to the possibility of error.
A randomly controlled trial was performed on 41 women having gynaecological surgery in which the team of surgeons and nurses wore or did not wear masks. After major abdominal surgery, 3 of 5 patients in the unmasked group developed wound infections whereas no infection was observed in the 4 patients of the masked group. A greater number of Streptococci were also found by settle-plates on the operating table in the unmasked group. No infection was recorded after minor or vaginal surgery.
Patients undergoing surgery are often overlooked for the prevention of pressure ulcers. Anesthetized patients are at very high risk for pressure injury due to forced immobility which occurs during surgery. This risk has been reported to be higher for patients undergoing vascular surgery. Few studies have been conducted which examine the tissue interface pressure of the conventional operating table pad and products available to reduce pressure for patients undergoing surgery. Several cases of pressure injury in patients undergoing vascular surgery led to this study.
INTRODUCTION: We describe a simple but effective modification of the skull clamp, aimed at stabilising the head of very young children, while avoiding the risk of creating a depressed skull fracture, in order to enable the utilisation of image-guidance in such young patients. METHODS: We machined three small perspex discs 3 cm in diameter. On the outer surface of these pads we drilled reception holes for the pins to prevent slippage. To avoid direct contact with the skin, we interfaced a thick pad of soft felt. During intraoperative positioning, the weight of the head was supported by a suction bean-bag placed on the operating table. Hence, the clamp apparatus was employed only to secure the head position, and not to support the weight of the head, thus requiring less clamp force. We employed this modification in three children (aged 9, 13 and 15 months) who required image-guided surgery for brain tumours. OUTCOME: In all cases the head remained immobile throughout the operation, making possible the accurate use of image guidance. At the end of the operation, some transient skin redness was noticed in the contact areas, which settled in a few days.
A TCT-300 scanner (manufactured by the Toshiba Co., Tokyo) has been installed in the operating room of Shinshu University Hospital since 1986. This neurosurgical operating CT scanner system was developed for obtaining intra- and postoperative CT images in the operating room. We have carried out immediate postoperative CT scanning in 206 cases: 170 were major and 36 were minor operations. A mobile CT scanner gantry has been used in 125 cases since June, 1988. We obtained CT images immediately after surgery on the digitalized operating table, the motion of which can be controlled as with the conventional CT scanner table. Immediate postoperative CT scans showed the extent of removed tumors or hematomas, position of the tip of ventricular or cisternal tubes, injury to the surrounding normal brain caused during the removal of lesions, and postoperative complications such as hemorrhage, brain swelling and surgical patties which had been inadvertently left in the wound. This CT scanner system in the operating room proved to be useful in the postoperative care of neurosurgical patients.
HYPOTHESIS: Since the advent of laparoscopic surgery in 1987 and the introduction of robotics into medicine in 1991, medical technology has advanced to robotic applications in performing surgery. In our study, we investigated the feasibility of performing simple laparoscopic maneuvers and laparoscopic cholecystectomy using a robotic surgical system. DESIGN: The study used a ZEUS robotic system (Computer Motion Inc, Goleta, Calif), consisting of 3 interactive robotic arms fixed at the operating table and remotely controlled by the surgeon. After initial training, using a bench model and 3 isolated porcine livers to perform cholecystectomy, 7 female pigs underwent robotically assisted laparoscopic cholecystectomy. The surgeon, seated at the console, manipulated the 3-mm laparoscopic instruments and performed the surgery. RESULTS: Robotically assisted laparoscopic cholecystectomy was accomplished in all 7 pigs, with a mean operative time of 46 minutes (range, 30-62 minutes). There were no complications. The mean time to setup of the robotic system decreased from 30 minutes to 14 minutes. All the robotic maneuvers were performed without any particular difficulties, and the movements were stable, accurate, and reliable, with good control. CONCLUSIONS: Our preliminary experimental study showed that robotically reproduced laparoscopic maneuvers, such as tying, suturing, dissection, clipping, and cautery, seemed to be as accurate and as fast as maneuvers made without robotics. We conclude that our initial experimental and animal study confirmed the feasibility of robotically assisted laparoscopic cholecystectomy. Further reports are needed to show that robotics can be used for clinical applications in surgery.
BACKGROUND: Elective splenectomy is often performed for hematological diseases, some of which cause only moderate enlargement of the spleen. The avoidance of an extensive upper abdominal incision is desirable in such cases and laparoscopic splenectomy offers significant potential advantages over the open operation if it can be performed safely and economically. METHODS: Eight consecutive patients underwent laparoscopic splenectomy. The operation was carried out with the patient at 40 degrees in the right lateral position so that rotating the operating table would make a full right lateral position possible. After fenestration of the gastrocolic omentum and division of the short gastric vessels, this position allowed the spleen to be pushed up under the diaphragm to facilitate access to the splenic vessels and the hilum. Vessels were divided individually between clips. RESULTS: All eight cases were completed laparoscopically. Mean length of operation was 259 min (range 230-285). Postoperative stay ranged from 2 to 7 days (median 4 days). There was no mortality, although minor complications did occur in three patients. CONCLUSIONS: We found laparoscopic splenectomy to be a safe and feasible procedure for the elective removal of the moderately enlarged spleen.
We present a case of a giant hepatic hemangioma. We found it at laparotomy and we decided on the course of treatment on the operating table. As right lobectomy was not feasible, we performed ligation of the hepatic artery. The patient made an uneventful recovery. A selective hepatic angiography and a liver scan were performed 8 months postoperatively and they both showed regression of the tumor. The tumor was not demonstrable in the right hepatic artery. The patient is in excellent health 2 years after the operation; the liver is smaller in palpation and the tumor itself is nonpalpable. In this case the ligation of the hepatic artery was a successful therapeutic procedure.
Prostate brachytherapy quality assessment procedure should be performed while the patient is still on the operating table since this would enable physicians to implant additional seeds immediately into the prostate if necessary thus reducing the costs and increasing patient outcome. Seed placement procedure is readily performed under fluoroscopy and ultrasound guidance. Therefore, it has been proposed that seed locations be reconstructed from fluoroscopic images and prostate boundaries be identified in ultrasound images to perform dosimetry in the operating room. However, there is a key hurdle that needs to be overcome to perform the ultrasound and fluoroscopy-based dosimetry: it is highly time-consuming for physicians to outline prostate boundaries in ultrasound images manually, and there is no method that enables physicians to identify three-dimensional (3-D) prostate boundaries in postimplant ultrasound images in a fast and robust fashion. In this paper, we propose a new method where the segmentation is defined in an optimization framework as fitting the best surface to the underlying images under shape constraints. To derive these constraints, we modeled the shape of the prostate using spherical harmonics of degree eight and performed statistical analysis on the shape parameters. After user initialization, our algorithm identifies the prostate boundaries on the average in 2 min. For algorithm validation, we collected 30 postimplant prostate volume sets, each consisting of axial transrectal ultrasound images acquired at 1-mm increments. For each volume set, three experts outlined the prostate boundaries first manually and then using our algorithm. By treating the average of manual boundaries as the ground truth, we computed the segmentation error. The overall mean absolute distance error was 1.26 +/- 0.41 mm while the percent volume overlap was 83.5 +/- 4.2. We found the segmentation error to be slightly less than the clinically-observed interobserver variability.
PURPOSE: Anorectal surgery has been increasingly performed as an ambulatory procedure using general, regional, and local anesthesia. Local anesthesia is classically performed through infiltration of four quadrants around the anal verge, which renders the procedure painful and uncomfortable for most surgeons and patients. We present a new, painless technique of local anesthesia for anorectal surgery. METHODS: Patients with surgical risk Classes I and II (American Society of Anesthesiologists) bearing anorectal pathologies were sedated and placed on the operating table in the prone jackknife position. After local antisepsis, the anal canal was lubricated with 2 percent lidocaine gel, and the mucosa was punctured by a hook-shaped, curved, 22-gauge needle just above the pectinate line. A solution of local anesthetics was slowly infused in all four quadrants to the submucosal level. If needed, more anesthetics were infused during the operation. RESULTS: This technique was easily and painlessly applied in more than 60 patients and permitted execution of several ambulatory anorectal procedures with comfort and safety. CONCLUSIONS: The hook-needle puncture for local anesthesia is an effective and safe procedure and may be routinely used for ambulatory anorectal surgery in selected patients.
The surgical treatment of kyphosis and kyphoscoliosis in children or adolescents using the Cotrel-Dubousset (C. D.) instrument through a posterior approach may often need a further anterior procedure either before or after. We have reviewed 20 adolescents who were operated on at l'Hôpital Saint Vincent de Paul since 1983. Our choice of management was determined by consideration of the aetiology, the age, the degree of angulation and the suppleness of the kyphotic spine in hyperextension on the operating table. The use of preoperative traction for a mean of 25 days gained an improvement of 14% of the final correction. It was used in the curves which were most pronounced, usually high thoracic curves which lacked suppleness in the lumbar spine and which were stiff on the table. The anterior approach was not indicated in long double dorso-lumbar curves, usually of idiopathic origin, which had already reached an advanced stage of development. It was necessary in severe angular kyphoses which were unstable or had marked anterior stiffness. It was sometimes used in younger patients with kyphoscoliosis in which it was difficult to assess the state of maturity. After operation the kyphosis was corrected by up to 73% in simply kyphoses, 66% in kyphoscoliosis and 59% in scolio-kyphosis. After operation we were usually able to mobilise patients without a corset.
Thoracoscopic surgery was performed in nine patients with benign mediastinal tumors: four neurogenic tumors, three bronchogenic cysts, a foregut cyst and a mature teratoma. Four cystic masses located in para-esophageal lesion in inferior mediastinum and four neurogenic tumors located in posterior mediastinum. A mature teratoma was adjacent to thymus in anterior mediastinum. Under general anesthesia with unilateral ventilation, the patients were turned in the lateral decubitus position and we tilt the operative table to allow gravity assistance for the displacement of the lung. A rigid telescope was inserted through a thracoport. Masses were resected using the dissecting scissors with electric cautery through two other thracoports. Thoracoscopic complete resections were performed in eight patients. In one case that was suspected of malignant tumor by preoperative evaluation, thoracoscopic tumor biopsy was performed and diagnosed as a benign neurogenic tumor during operation histopathologically. But it was resected by thoracotomy, because of its larger size (8 cm in diameter). The average operation time was 122 minutes ranging from 80 to 184 minutes in 8 patients with thoracoscopic resection. No patient has a complication resulting from the thoracoscopic surgery. The chest drainage tubes were removed on 1 or 2-POD in all cases and the average length of postoperative hospitalization was 5.3 days ranging from 4 to 9 days. The thoracoscopic resection for benign mediastinal tumors is minimally invasive and effective procedure compared with classical thoracotomy operation.
INTRODUCTION: A mobile computed tomographic scanner has been developed in which the scan plane is selected by means of gantry translation, rather than by translation of the patient table. This permits computed tomographic scanning in situ of any patient who is positioned on a radiolucent surface that fits within the inner diameter of the gantry. We report the design of and initial experience with this scanner as used with adapters for intraoperative and bedside computed tomography (CT). METHODS: The scanner is equipped with wheels, draws power from wall outlets (120 V, 20 A) in combination with batteries, and has a translating gantry. Preclinical studies of image quality were performed with phantoms. An operating table adapter was built for use with a radiolucent cranial fixation device. A bedside adapter was built that holds the head and shoulders of a patient in the intensive care unit. RESULTS: The preclinical phantom studies showed satisfactory image spatial resolution (0.8 mm) and low-contrast resolution signal-to-noise relative standard deviation (0.37%). Experience to date with 12 patients has confirmed the feasibility of intraoperative CT on demand. Experience to date with 26 patients has confirmed the feasibility of routine bedside CT in the intensive care unit. CONCLUSION: With these adaptations, mobile CT may increase the efficiency of intraoperative scanning by making it available to multiple operating rooms without committing it to any room for an entire operation and may increase the efficiency and safety of CT of critically ill patients who currently need to leave the intensive care unit to travel to a fixed CT installation and back.
A retractor support consisting of an inverted L-rod, fastened to the operating table with a clamp, can be applied in a variety of ways to maintain retraction more conveniently and reliably in some circumstances than a human assistant. Through universal joints and connecting rods it can be quickly adjusted to hold a Weinberg retractor, a BiBall retainer, a rectangular frame for multidirectional retraction in vascular repair, or a ribbon retractor for herniotomy, pneumonectomy and lobectomy. By freeing the assistant this device can shorten operating time and permit cumbersome procedures to be accomplished by a surgeon and one assistant with less operative trauma.
INTRODUCTION: With regards to the use of bariatric surgery on very obese patients and prolonged interventions, isolated cases of a compartment syndrome by compression and secondary rhabdomyolysis have been described. We describe a case which presented with a compartment syndrome, rhabdomyolysis and neuropathy of the common sciatic nerve. CLINICAL CASE: A 39 year old male with morbid obesity and high blood pressure, who after being subjected to 5 hours long bariatric surgical intervention, presented with intense pain, muscle binding and paresis in the musculature dependent on left common sciatic nerve. A creatinkinase (CK) level of 78,000 IU and volume increase of the left gluteal compartment were noted. On serial computarized tomography scans this increased leading to gluteal atrophy and ischiotibials. Evolution was negative without functional recovery and poor pain control. The patient presented with a compartment syndrome and secondary rhabdomyolysis triggered by the pressure on the gluteal zone on the operating table. The prolonged duration of the surgery, obesity and microvascular affectation due to hypertension, could be factors implicated in the development of the syndrome. The affectation of the sciatic nerve, not described as a complication of this type of surgery, is explained by pressure exercised on the compartment block on the sciatic nerve, with secondary ischaemia. CONCLUSIONS: Early determination of CK, carrying out postural changes during surgery and early post-operative neuromuscular examination, looking for signs of compartment syndrome, should be systematically carried out after bariatric surgery. The early carrying out of a decompressive fasciotomy considering a compartment syndrome could reduce or avoid the neurological complications.
PURPOSE: To compare the effect of xylocaine jelly and intracameral lidocaine with one quadrant instant sub-Tenon infiltration for self-sealing sclerocorneal phacoemulsification. METHODS: One hundred patients were enrolled into a prospective randomized study, receiving either a combination of topical 2% xylocaine jelly and 0.5 ml of intracameral 1% lidocaine or sub-Tenon infiltration with 2 ml of 2% xylocaine on the operating table. All patients underwent a standard divide and conquer phacoemulsification procedure through a superior sclerocorneal frown incision followed by implantation of a polymethylmethacrylate intraocular lens. Intraoperative pain was indicated by the patient by squeezing the bedside nurse's hand, who allocated it to particular stages of surgery on a chart. After surgery, patients assessed the pain experienced using a 10-unit visual analogue scale. RESULTS: Pain was indicated on 31 occasions during the operation in the sub-Tenon group (mainly the injection itself) and 67 times in the topical group. The median overall subjective pain score was 3 in the jelly group and 0 in the sub-Tenon. Five eyes (10%) had to be converted to sub-Tenon during the surgery because of intolerable pain. CONCLUSIONS: Whereas lidocaine supported xylocaine jelly anesthesia provided acceptable analgesia for 90% of patients operated, sub-Tenon anesthesia proved to deliver better intraoperative comfort in all patients receiving sclerocorneal incision cataract surgery.
BACKGROUND: The anterior transabdominal approach for adrenalectomy is associated with a longer postoperative recovery period than a posterior extraperitoneal adrenalectomy. The posterior approach is useful for patients requiring bilateral adrenalectomy or in those undergoing unilateral adrenalectomy for benign adenomas smaller than 5 cm. Recently transabdominal laparoscopic adrenalectomy has been used in patients with adrenal tumors. Endoscopic retroperitoneal adrenalectomy (ERA) is an alternative method that provides excellent exposure and should be associated with less postoperative morbidity. METHODS: Between 1993 and 1994 11 ERAs were performed in eight patients in the Department of Surgery, Istanbul Faculty of Medicine. The patients were placed in the prone semijackknife position on the operating table. After the retroperitoneal space was expanded with a balloon trochar, four 10 mm trochars were placed to perform the procedure. RESULTS: Among the eight female patients 23 to 65 years of age (mean, 42 +/- 12.4 years), three had bilateral adrenal hyperplasia caused by Cushing's disease, three patients had functioning adenoma, one patient had nonfunctioning adenoma (three on right and one on left adrenal), and one patient had right adrenal cyst. The mean operation time was 150 minutes (range, 90 to 300 minutes). No changes in PCO2 values have been found during intraoperative blood gas analyses. No intraoperative or postoperative complications occurred. All patients were discharged on the third postoperative day. CONCLUSIONS: ERA is a new and safe method of adrenalectomy. It is less invasive than the posterior approach. Patients treated by ERA seem to experience less postoperative pain and discomfort and have a shorter postoperative hospitalization and recovery period.
This paper describes a nonstandard procedure for total knee replacement (TKR), based on the use of modern tools such as computers, electronic sensors, and robots, to achieve accurate and optimal implant results. The intervention is planned on a standard PC connected to the CT scanner. Dedicated software shows the surgeon limb alignment and knee status and assists in the choice of the best prosthesis. The intervention is then performed with a new device and surgical procedure. At first the femur and the tibia are fixed to the operating table with a special clamp and the knee bones are exposed with the standard technique; then the surgeon digitizes the shape of the joint and the computer transfers the planned surgical strategy to a dedicated surgical robot. Resections are performed by the surgeon on a constrained guide held by the robot. In this paper we summarize the main results on the system performances, and discuss the clinical implications of this new technology in the operating room. Preliminary experiments on cadavers and volunteers show that this methodology can improve the accuracy of the implant to 2.5 mm and 20, reduce operating time and surgical errors, and may represent a challenging alternative methodology for TKR.