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Improving radiology in surgery.

The time has come to reevaluate the use of films of substandard quality obtained from outdated radiography equipment. The authors recommend that surgical subspecialists, orthopedic surgeons, emergency room physicians, gastroenterologists, or whoever employs radiology in the operating room ensure that technological progress in radiology be transferred to the surgical area. The mobile C-arm image amplifier with television fluoroscopy and single-image storage device should be considered for orthopedic surgery and ER rooms. More sophisticated equipment is required for operative cholangiography and operative angiography.

Data Display↗

[Neuromonitoring in the operating room and in the intensive care unit: a neurophysiologic technique for non-neurophysiologists?].

The successfulness of neuromonitoring in the operating room and intensive care unit relies on an adequate choice of the neurophysiological tool (electroencephalogram or evoked potentials), which should correctly target the neural structure at risk, be sensitive to the pathophysiological process feared, and correctly disentangle pathological and non-pathological factors. The neurophysiological information should be coded into a message readily interpretable by non-neurologists and continuous neuromonitoring should be provided.

Humans↗

Using prospective outcomes data to improve morbidity and mortality conferences.

Background:Though a traditional part of most training programs, surgical morbidity and mortality (M&M) conferences are not optimal for teaching residents how to understand and improve patient outcomes. They tend to focus on unusual rather than common problems and review complications as singular phenomena, rather than recurrent events related to specific processes of care. For these reasons, we began incorporating data from our general surgery outcomes registry into our M&M conference.Developed for both clinical research and quality improvement purposes, the outcomes registry contains prospective information about all patients undergoing general surgery procedures in the operating room (approximately 2000 per year). All adverse events occurring within 30 days of surgery are categorized, using explicit criteria, by clinical nurse coordinators. Individual complications are then collapsed into four severity grades (from a previously validated grading system), from I (not life-threatening, low complexity therapy; eg, superficial wound infection) to IV (death).Application To M&M Conferences:Before each conference the data manager supplies the responsible senior resident with information about caseloads and adverse events for the preceding month. At the conference, individual cases are presented in the context of the department's broader experience with that procedure (eg, rates of wound complications after bowel surgery over the last 2 years). In reviewing trends in complication rates over time, we also explore potential relationships between practice changes and outcomes. When appropriate, local performance is compared to external "benchmarks" using data from published studies.Incorporating prospective outcome data into the M&M conference is both feasible and practical. In addition to its educational value for both resident and attending physicians, we believe this approach creates many opportunities for improving the quality of our surgical practice.

Journal Article↗

[Off-pump coronary artery bypass grafting using donut and SPY].

Off-pump coronary artery bypass grafting (OPCAB) has been rapidly increased, because of its less invasiveness with low complications. However, graft patency rate highly depends on operators' capability due to technical difficulties. In this article, detail operative procedures are introduced to perform OPCAB in 100% for isolated coronary patients. Selecting better stabilizer may be a key of success. Donut Heart Stabilizer can make a still and stable operative field to anastomose less than 1 mm coronary artery. It is very useful to achieve complete revascularization for all stenosed coronary branches. OPCAB with 9 arterial grafts could be done using Donut. SPY Intra-operative Imaging System is also important to get 100% patency rate of the grafts. Using SPY, we can avoid graft trouble during operation in operation room (OR). SPY image is the best key information for operators to decide revision of the failed grafting. Donut 2 Heart Stabilizer has been improved to make more wide and stable operative field. Donut and SPY is the best combination for OPCAB.

3',5'-Cyclic-AMP Phosphodiesterases↗

An automated simultaneous transmural cardiac mapping system.

The origin and propagation sequence of cardiac depolarization in situ requires accurate simultaneous three-dimensional information from multiple sites. Likewise, the mechanism underlying an arrhythmia can often be elucidated by determining the course of impulse propagation through the heart, particularly if information can be obtained from multiple sites simultaneously, allowing analysis of transient or rapidly occurring events. The most significant problem with obtaining such detailed continuous information is the large amount of data storage required as well as the need for rapid analysis. In the present system these problems are overcome by immediate conversion of all electrograms from analog to digital for all subsequent storage and processing. The bipolar electrogram information is acquired from 240 cardiac sites simultaneously at a sampling rate of 2 kHz with continuous and total data storage of up to 60 min. Rapid two-dimensional isochronic maps at multiple depths (effective 3-dimensional information) are presented via computer-generated interactive graphics. System design permits easy expansion to almost 2,000 simultaneous sites. Surgical electrophysiological intraoperative studies in humans are performed at an operating room located 2,000 ft from the computer facility with all communications carried by a fiber-optic link. The system allows both experimental and clinical cardiac mapping from multiple sites from a single cardiac depolarization, minimal redundancy of costly hardware, and direct rapid visualization of all original electrogram data.

Arrhythmias, Cardiac↗

[Treatment of patent ductus arteriosus. Comparison of costs between surgical and trans-catheter closures in a public institution].

UNLABELLED: The costs of transcatheter closure of patent ductus arteriosus in relation to the surgical closure still a controvertial issue in our hospitals. The aim of the study was compared the costs of both treatments. METHODS: We included 57 patients treated with transcatheter occlusion and 26 underwent surgery. Information about laboratory tests, average in hospital days of stay, anesthesia type and duration, operating and hemodinamic room costs, was gather. A database containing the costs from the institution unitary costs system in force was designed. RESULTS: sociodemographyc characteristics were similar in both groups. Ductus size was larger in patients treated with surgery (p<0.05). In hospital stay, as well as, the number of complications after the procedure were less in the patients treated with transcatheter occlusion (p<0.05). The closure with Amplatzer device was more expensive than the surgical one, and both were more expensive than coil. With surgical treatment, 86.5% of the costs are due to in hospital stay, with the Amplatzer this issues represented a 36%, however, the cost of the devices by itself represents a 40% of the total treatment cost. CONCLUSIONS: Even though total charges of Amplatzer devices are more expensive than surgery, transcatheter occlusion represents advantages in relation to less in hospital stay, resources used and number of complications, which allows hospital resources optimization.

Cardiac Catheterization↗

The operating room of the future: a view from Europe.

The Operating Room of the Future will be characterized by meticulous preoperative planning, full integration of the operating room into the general flow of information, more comprehensive intraoperative diagnostic imaging procedures, and the use of sophisticated visualization processes including augmented reality. Mechatronic support (partially autonomous robots) enhances safety and allows reduction of staff. Integrated operating room systems will allow the wide spectrum of new devices and functionalities to be easily controlled by the operating team. The Operating Room of the Future will no longer be isolated from the rest of the clinical endeavor. Intraoperative teleconsultation and telepresence will help to promote and teach safer evidence-based endoscopic therapeutic surgery. Traditional surgical intervention will expand its definitions by procedures via an interdisciplinary, cooperative approach that will replace the sequential therapeutic process of today.

Europe↗

Reorganizing patient care and workflow in the operating room: a cost-effectiveness study.

BACKGROUND: Many surgeons believe that long turnover times between cases are a major impediment to their productivity. We hypothesized that redesigning the operating room (OR) and perioperative-staffing system to take advantage of parallel processing would improve throughput and lower the cost of care. METHODS: A state of the art high tech OR suite equipped with augmented data collection systems served as a living laboratory to evaluate both new devices and perioperative systems of care. The OR suite and all the experimental studies carried out in this setting were designated as the OR of the Future Project (ORF). Before constructing the ORF, modeling studies were conducted to inform the architectural and staffing design and estimate their benefit. In phase I a small prospective trial tested the main hypothesized benefits of the ORF: reduced patient intra-operative flow-time, wait-time and operative procedure time. In phase II a larger retrospective study was conducted to explore factors influencing these effects. A modified process costing method was used to estimate costs based on nationally derived data. Cost-effectiveness was evaluated using standard methods. RESULTS: There were 385 cases matched by surgeon and procedure type in the retrospective dataset (182 ORF, 193 standard operating room [SOR]). The median Wait Time (12.5 m ORF vs 23.8 m SOR), Operative Procedure Time (56.1 m ORF vs 70.5 m SOR), Emergence Time (10.9 m ORF vs 14.5 m SOR) and Total Patient OR Flowtime (79.5 m ORF vs 108.9 m SOR) were all shorter in the ORF (P < .05 for all comparisons). The median cost/patient was $3,165 in the ORF (interquartile range, $1,978 to $4,426) versus $2,645 in SORs (interquartile range, $1,823 to $3,908) (P = ns). The potential change in patient throughput for the ORF was 2 additional patients/day. This improved throughput was primarily attributable to a marked reduction in the non-operative time (ie, those activities commonly accounting for "turnover time") rather than facilitation of faster operations. The incremental cost-effectiveness ratio of ORF was $260 (interquartile range, $180 to $283). CONCLUSION: The redesigned perioperative system improves patient flow, allowing more patients to be treated per day. Cost-effectiveness analysis suggests that the additional costs incurred by higher staffing ratios in an ORF environment are likely to be offset by increases in productivity. The benefits of this system are realized when performing multiple, short-to-medium duration procedures (eg, <120 m).

Cost-Benefit Analysis↗

Virtual reality, telesurgery, and the new world order of medicine.

We are seeing the emergence of medical applications for virtual reality (VR). These include telepresence surgery, three-dimensional (3-D) visualization of anatomy for medical education, VR surgical simulators, and virtual prototyping of surgical equipment and operating rooms. Today, approximately 90% of the knowledge a physician requires can be obtained through electronic means, such as diagnostic sensors and imaging modalities, directly seeing the patient with a video camera for medical consultation, or using electronic medical records. In addition, with telepresence, a therapy can be effected electronically, regardless of the physical location of the patient. Therefore, it makes sense to send the electronic information or manipulation, rather than sending the patient or blood samples, to obtain tests or to produce a cure. In that these applications are mediated through the computer interface, they are the embodiment of VR as the major force for change in the field of medicine. The Green Telepresence Surgery System consists of two components, the surgical workstation and the remote worksite. At the remote site are a 3-D camera system and responsive manipulators with sensory input. At the workstation are a 3-D monitor and dexterous handles with force feedback. The next generation in medical education can learn anatomy from a new perspective by "flying" inside and around the organs, using sophisticated computer systems and 3-D visualization. The VR surgical simulator is a stylized recreation of the human abdomen with several essential organs. Using this, students and surgeons can practice surgical procedures with virtual scalpels and clamps. To support these advanced technologies, the operating room and hospital of the future will first be designed and tested in virtual reality, allowing multiple iterations of equipment and surgical rooms before they are actually built. Insofar as all these technologies are based on digital information, they are the building blocks for the digital physician of the 21st century.

Computer Simulation↗

A computerized medical record. "The Balsfjord system".

The "Balsfjord system" is a fully computerized system of medical records. The system is developed by the University of Tromsö in cooperation with the district physicians in Balsfjord. It is designed for Norwegian general practice based on microcomputers. Each general practitioner has a computer terminal in his/her consulting room, and all the terminals can operate on the same file simultaneously. The main archive is a hard disc, in addition there is a a secondary diskette archive for old, out of date record versions. Each medical record is composed of seven components, where the medical information is logically organized. The system is able to print out prescriptions, sick-leave forms, and parts or the whole record. Included in the program are two statistical systems. One is based on data from encounters, and the other is a search and statistical system based on the individual record as the unit. The system has been very successful for the two and a half years it has been in use. Both the doctors and the ancilliary staff have appreciated the system in their daily work.

Computers↗

Force sensor for laparoscopic Babcock.

UNLABELLED: GENERAL: A force sensor has been designed and fabricated that will fit to existing laparoscopic grasping forceps (Babcocks) from Ethicon Endosurgery Inc. The goal of the sensor development is to provide tool-tissue force information to the surgeons so that surgeons can regain the sense of touch that has been lost through laparoscopy. Eventually, force sensing will provide feedback for robotic laparoscopic surgical platforms. OBJECTIVE: We have developed a prototype force sensor system with ATI Industrial Automation. This tool is provided as an in-line transducer with six degrees of freedom that can retrofit current Babcocks. The sensor is currently being used in clinical trials with animals to determine the benefits. The sensor system utilizes industry proven technology in combination with a custom transducer and user interface. A GUI is part of the system and provides resolved force magnitude data in a graphical format for case of interpretation. Sterilization, size, and ease of use are addressed by the current design. Operating room reliability and safety are currently being investigated. CLINICAL TRIAL: A three phase experimental trial using a porcine model is being completed that will test the hypothesis that force information can be used to minimize tissue trauma during laparoscopic surgery. RESULTS: Based on our research, there is strong evidence that surgeons would benefit from information regarding the levels of force applied to tissues. In the future, robotic surgery will require force sensing. Surgical simulators could provide force feedback during simulated surgical procedures by using a sensor platform such as this. In addition, tool tip design in the future will benefit from the application of this technology and data base.

Animals↗

Retrospective cost analysis comparing Essure hysteroscopic sterilization and laparoscopic bilateral tubal coagulation.

STUDY OBJECTIVE: To compare the institutional cost of permanent female sterilization by Essure hysteroscopic sterilization and laparoscopic bilateral coagulation. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Midwestern academic medical center. PATIENTS: Women of reproductive age who elected for permanent contraception by the Essure method (n = 43) or by laparoscopic tubal coagulation (n = 44) during the time frame studied. INTERVENTIONS: Placement of the Essure inserts according to the manufacturer's instructions or laparoscopic tubal sterilization using bipolar forceps according to standard techniques of open or closed laparoscopy. MEASUREMENTS AND MAIN RESULTS: Cost-center data for the institutional cost of the procedure was abstracted for each patient included in the study. In addition, demographic data and procedural information were obtained and compared for the patient populations. The Essure system of hysteroscopic sterilization had a significantly decreased cost compared with laparoscopic tubal sterilization when both procedures were performed in an operating room setting. The decrease per patient in institutional cost was 180 dollars (p = .038). This included the cost of the confirmatory hysterosalpingogram 3 months after Essure placement and the cost of laparoscopic tubal occlusion by Filshie clip if the Essure micro-inserts could not be placed. The majority of the cost was related to hospital costs as opposed to physician costs. The Essure procedure had higher costs for disposable equipment (p <.0001), but this was offset by higher charges for operating room costs, which included the recovery room (p <.0001) and pharmacy costs (p <.0001) in the patients in the laparoscopy group. CONCLUSION: In our setting, the Essure hysteroscopic sterilization had significant cost savings compared with laparoscopic tubal sterilization (p = .038). We believe that our data represent the minimum of potential savings using this approach, and future developments will only increase the cost difference found in our study.

Adult↗

Preoperative evaluation of pediatric surgical patients with multisystem considerations.

Fewer and fewer patients spend time in the hospital in advance of a surgical or interventional procedure requiring anesthesia care. As a result, there is increasing reliance on a thorough preoperative evaluation directed toward identifying anesthetic risks. For this to occur, each medical institution must have a clear and comprehensive system that processes patients during the preoperative period. There are specific and unique personnel and system requirements for the accumulation of multidisciplinary information in the pediatric patient population. The justification for the cost of this type of program is the savings realized by the decrease in wasted operating room time due to inadequate or incomplete patient preparation. The following is a description of a successful perioperative evaluation and preparation process that has been in place for 7 yr in a major pediatric academic institution.

Ambulatory Surgical Procedures↗

Physiologic monitoring systems.

Physiologic monitoring systems monitor vital physiologic parameters so that clinicians can be informed of changes in a patient's condition. They typically consist of several distinct components, including a central station, bedside monitors, and ambulatory telemetry transmitters and receivers. We previously evaluated physiologic monitoring systems in our January-February 1999 issue (Health Devices 28[1-2]). For this update, we have tested systems from two additional suppliers, using the same criteria and test methods that we used for the eight systems in the original study. As in the earlier Evaluation, we have examined how each system functions as a whole, rather than focusing on the performance of individual components. We judged the systems primarily on adaptability, alarm implementation, and human factors design. In the Conclusions, we compare all 10 units evaluated to date. We also provide updated product information for the systems evaluated in our original study; in some cases, the changes that have been made to those systems have caused us to revise our ratings. We rated all the systems based on their capabilities for each of six applications: (1) critical care unit, (2) emergency department, (3) intermediate care unit and general medical/surgical floor, (4) operating room, (5) postanesthesia care unit, and (6) transport. As in our earlier study, we have determined that most of the evaluated systems have drawbacks for one or more of the evaluated applications. In our January-February 1999 Evaluation of physiologic monitoring systems (Health Devices 28[1-2]), we discussed the issues surrounding the purchase and use of these systems. In this introduction, we recap the most significant points from that discussion, provide some new information about ambulatory telemetry and wireless networks, and briefly describe the components of this Update Evaluation.

Equipment Design↗

Virtual reality in surgery and medicine.

This report documents the state of development of enhanced and virtual reality-based systems in medicine. Virtual reality systems seek to simulate a surgical procedure in a computer-generated world in order to improve training. Enhanced reality systems seek to augment or enhance reality by providing improved imaging alternatives for specific patient data. Virtual reality represents a paradigm shift in the way we teach and evaluate the skills of medical personnel. Driving the development of virtual reality-based simulators is laparoscopic abdominal surgery, where there is a perceived need for better training techniques; within a year, systems will be fielded for second-year residency students. Further refinements over perhaps the next five years should allow surgeons to evaluate and practice new techniques in a simulator before using them on patients. Technical developments are rapidly improving the realism of these machines to an amazing degree, as well as bringing the price down to affordable levels. In the next five years, many new anatomical models, procedures, and skills are likely to become available on simulators. Enhanced reality systems are generally being developed to improve visualization of specific patient data. Three-dimensional (3-D) stereovision systems for endoscopic applications, head-mounted displays, and stereotactic image navigation systems are being fielded now, with neurosurgery and laparoscopic surgery being major driving influences. Over perhaps the next five years, enhanced and virtual reality systems are likely to merge. This will permit patient-specific images to be used on virtual reality simulators or computer-generated landscapes to be input into surgical visualization instruments. Percolating all around these activities are developments in robotics and telesurgery. An advanced information infrastructure eventually will permit remote physicians to share video, audio, medical records, and imaging data with local physicians in real time. Surgical robots are likely to be deployed for specific tasks in the operating room (OR) and to support telesurgery applications. Technical developments in robotics and motion control are key components of many virtual reality systems. Since almost all of the virtual reality and enhanced reality systems will be digitally based, they are also capable of being put "on-line" for tele-training, consulting, and even surgery. Advancements in virtual and enhanced reality systems will be driven in part by consumer applications of this technology. Many of the companies that will supply systems for medical applications are also working on commercial products. A big consumer hit can benefit the entire industry by increasing volumes and bringing down costs.(ABSTRACT TRUNCATED AT 400 WORDS)

Computer Simulation↗

Computer-aided fixation of spinal implants.

Medical imaging provides an important basis for modern diagnosis as well as for preoperative planning of surgical procedures. However, information gained cannot be transferred directly into the operating room. Furthermore, the safety and accuracy of the surgical intervention would be improved by interactive navigation of surgical instruments. These features are provided by the system for computer-aided fixation of spinal implants described in this paper.

Computer Simulation↗

Cortical surface registration for image-guided neurosurgery using laser-range scanning.

In this paper, a method of acquiring intraoperative data using a laser range scanner (LRS) is presented within the context of model-updated image-guided surgery. Registering textured point clouds generated by the LRS to tomographic data is explored using established point-based and surface techniques as well as a novel method that incorporates geometry and intensity information via mutual information (SurfaceMI). Phantom registration studies were performed to examine accuracy and robustness for each framework. In addition, an in vivo registration is performed to demonstrate feasibility of the data acquisition system in the operating room. Results indicate that SurfaceMI performed better in many cases than point-based (PBR) and iterative closest point (ICP) methods for registration of textured point clouds. Mean target registration error (TRE) for simulated deep tissue targets in a phantom were 1.0 +/- 0.2, 2.0 +/- 0.3, and 1.2 +/- 0.3 mm for PBR, ICP, and SurfaceMI, respectively. With regard to in vivo registration, the mean TRE of vessel contour points for each framework was 1.9 +/- 1.0, 0.9 +/- 0.6, and 1.3 +/- 0.5 for PBR, ICP, and SurfaceMI, respectively. The methods discussed in this paper in conjunction with the quantitative data provide impetus for using LRS technology within the model-updated image-guided surgery framework.

Adult↗