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PubMedDate not supplied

Endovascular exclusion of thoracic aortic aneurysms: mid-term results of elective treatment and in contained rupture.

PURPOSE: The purpose is to present results of endovascular exclusion (stent-graft treatment) of aneurysms of the descending thoracic aorta both in elective cases and in emergencies. METHODS: Indications for stent-graft treatment were dependent on multislice angio-CT evaluation revealing a proximal neck of at least 10 mm between the left common carotid artery and the onset of aneurysm. All stent grafts were inserted in the operating room; 43 transfemoral, 2 transiliac. The stent grafts used were Corvita, Stenford, Vanguard, AneuRx, Talent, and Excluder. Deployment was achieved under fluoroscopic control, endoleaks were checked for with D S A on the operating table and postoperatively by angio-CT. Long-term follow-up consisted of evaluation with angio-CT after 6 and 12 months, and from there on once a year and with plain chest X-rays. Follow-up was achieved in all patients. RESULTS: Mean follow-up is 21 months (1-66); 30-day mortality is 3/45, no permanent neurologic deficit. Thirty patients were treated electively, 15 with contained rupture. Left subclavian artery overstenting proved to be necessary in 12 patients for proper proximal sealing of the aneurysm, type I endoleaks were observed in 10 patients, one early conversion, 7 proximal extension cuffs, one sealed spontaneously, one still at risk. Among patients where LSA had been overstented only one wanted a transposition, all others did well without left-hand ischemia or subclavian steal syndrome. CONCLUSION: Endovascular treatment is less invasive and has reasonable mortality and morbidity but is limited to well-defined morphologies. Mid-term results are promising but it has to be observed whether these will translate into long-term durability.

Aged↗
PubMed1998

Bilateral breast reconstruction in very thin patients with extended free TRAM flaps.

A lateral extension of the free TRAM flap design is described for use in unusually thin patients who desire bilateral autologous tissue breast reconstruction. Because of the exceptionally good blood supply to the free TRAM flap, the lateral extensions are viable even when the flap is folded double to increase its thickness and projection. To increase the volume of the reconstructed breast, the flaps can be extended as far laterally as the surface of the operating table will permit. With this approach, bilateral TRAM flap breast reconstruction is possible even for extremely thin patients.

Female↗
PubMed2005

[A new method for computer-assisted orbitotomies].

BACKGROUND: Surgical planning and tumor margins from preoperative image data sets can be transferred to the surgical site by use of computer-assisted navigation systems. Usually registration markers are placed prior to image data acquisition in order to correlate the patient's preoperative image data set with his/her position in the operating room. Pointers are commonly used for navigation, and the position of the pointer within the surgical site is compared to its position within the image data set. With a new navigation system, patient registration can be performed without registration markers. Tumor margins and osteotomy lines can be projected onto the surgical site. MATERIALS AND METHODS: With the new navigation system, which has been developed by the Sonderforschungsbereich 414 of the Deutsche Forschungsgemeinschaft, markerless patient registration is performed using the contours of the patient's face. A scanner is mounted above the operating table, which detects the surface of the surgical site intraoperatively. Osteotomy lines and tumor margins are projected onto this surface using an intense beamer. The procedure is illustrated for a patient with a meningeal tumor of the orbit. RESULTS: Patients can be registered with an accuracy of 1 mm. Pointers are not required to transfer the data on the surgical site. Furthermore, monitors are no longer required, since the information is projected directly on the patient's surface. CONCLUSIONS: Surgical planning and tumor margins can exactly be visualized within the surgical site. Ergonomics are especially improved for navigated orbitotomies via a coronal approach.

Adult↗
PubMed2005

[Polytrauma with tension pneumothorax with inserted chest tube].

The authors report a case of a 25-year-old woman with a polytrauma, caused by a free fall of 12 metres in suicidal intention. Following endotracheal intubation and mechanical ventilation by an emergency physician at the scene, the patient was delivered to the emergency room of an university hospital. An ultrasonic check of the abdomen revealed free fluid in the abdominal cavity, and a rupture of liver and spleen was suspected. Since breath sounds over the right lung were diminished, a chest tube was inserted immediately in the fifth intercostal space in the anterior axillary line. About 300 millilitres of blood were drained by the tube. Shortly thereafter, a laparotomy was performed, where spleen and liver rupture were confirmed and treated. After 60 minutes, the patient developed severe hypotension coupled with ventricular tachycardia and fibrillation, and resuscitation measures had to be initiated. Since breath sounds over the right lung were missing, a tension pneumothorax was suspected and a thoracotomy performed immediately. While huge amounts of air and blood were emerging from the thoracic cavity, a rupture of the right mainstem bronchus as well as of the right pulmonary artery and vena subclavia was identified. The chest tube was found dislocated into the subcutaneous tissue. Despite of open heart compression, application of adrenaline and noradrenaline and substitution of packed red blood cells and of crystalloid and colloid solutions, all resuscitation measures failed so that the patient died shortly after on the operation table. This case illustrates first the difficulties of an adequate thoracic trauma management, particularly, when clinical symptoms are discrete, second the problems of the insertion and control of a chest tube, and third risks associated with wrong position or secondary dislocation which may include - as in our case - "masking" of severe injury patterns and delay of life-saving measures such as an immediate thoracotomy. In order to improve prognosis of patients with poly-/thoracic trauma, establishment of spiral-CT in emergency centres, routine bronchoscopy and safe handling of chest tubes may be helpful.

Adult↗
PubMed1984

Postoperative disc entrapment following cardiac valve replacement--a report of ten cases.

The sudden jamming of a prosthetic valve disc is one cause for postoperative hemodynamic deterioration. This complication occurred in 10 instances (2% of disc valves implanted), resulting in 4 fatalities. In 6 patients the disc entrapment was a complication following mitral valve replacement, and in 4 others the malfunction followed aortic valve surgery. The entrapment of the disc occurred on the second postoperative day in 3 patients. Two of these were due to an unresected chordal strand becoming wedged between the disc and valve rim of a Björk-Shiley mitral prosthesis and resulted in death. In the third patient, the aortic valve disc became attached to the Björk-Shiley composite aortic graft following the repair of an aortic dissection. A firm blood clot had formed between the graft and the oversewn aortic wall. This patient recovered after cardiopulmonary resuscitation and subsequent reoperation. The remaining cases developed while the patients were still either on the operating table or in the recovery room. The mechanisms of the disc entrapments are presented and the significance of an early correct diagnosis and urgent surgical correction is underlined.

Adult↗
PubMed1994

[Intraoperative thrombolysis with rt-PA in massive pulmonary embolism during venous thrombectomy].

In patients with deep venous thrombosis, there is a recent trend towards surgical thrombectomy to avoid late complications. However, up to 10% of these patients suffer from severe intraoperative pulmonary embolism, 30 to 40% of whom die on the operating table. Treatment options for massive pulmonary embolism include embolectomy (high mortality), transvenous thrombus fragmentation techniques, and thrombolytic therapy. However, while thrombolysis is recommended as the treatment of choice for PTE, it is usually considered contraindicated in surgical patients because of bleeding complications. We report on 5 cases of severe pulmonary thromboembolism with marked cardiogenic shock during venous thrombectomy. Three patients were treated successfully by intraoperative thrombolysis alone or in combination with mechanical fragmentation of the embolus using a catheter technique under fluoroscopy (one case). Diagnosis was established by a sudden decrease of mean arterial pressure (from 83 to 45 mmHg), a marked increase of mean pulmonary artery pressure (MPAP) (from 16 to 43 mmHg), hypoxaemia (SaO2 < 90%), an increased arterial-to-end-tidal CO2-difference (from 7 to 42 mmHg), and/or pulmonary angiography (2 cases). All patients had to be treated with high dosages of catecholamines (norepinephrine 0.5 microgram.kg-1.min-1 or epinephrine 0.1 microgram.kg-1.min-1, and dopamine 6-15 micrograms.kg-1.min-1). Three patients required CPR prior to or during thrombolytic therapy. Thrombolysis was started intraoperatively with rt-PA with dosages ranging from 20 to 90 mg, applied in single injections (5-75 mg) followed by infusions (5 or 10 mg.h-1) for up to 8 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1983

[Intraoperative lymphoscintigraphy in radical surgery of cancer].

The use of a gamma-camera operating table and the intraoperative lymphoscintigraphy using 99mTc-Antimony sulfide in radical surgery of carcinoma of the breast allows a better control of axillary lymphadenectomy. Remained lymph nodes are localized by an indicator filled with technetium and removed secondarily. Due to this technique it is possible to control and increase the extent of the axillary lymphadenectomy. Since the introduction of intraoperative axillary lymphoscintigraphy 83 patients were treated by mastectomy and axillary lymphadenectomy. In 48 cases complete lymphadenectomy could be obtained.

Antimony↗
PubMed1982

[Endoscopy of the nose as an aid in lacrimal duct surgery].

Endoscopy of the nose is a recently-adopted supplementary procedure for examining the tear drainage system. This examination is performed under local anesthesia with the patient on the operating table. We use a Hopkins endoscope with 30 degrees and 70 degrees deflections, diameter 2.7 mm and 4 mm. Endoscopy prior to dacryocystorhinostomy enables the examiner to judge whether the nasal cavity is large enough for an osteotomy. The orifice of the nasolacrimal duct is visible directly through the endoscope, so that the dye test can be rendered fairly objective. Endoscopy also enables the course of healing of the nasal ostium after surgery to be studied. We observed complications, such as granular tissue and synechiae developing between the posterior flap of the nasal mucosa, the middle turbinate and the nasal septum. Granulation tissue may be removed under endoscopic control. If an intubation of the lacrimal system is attempted, it may be easier to find the end of the steel probe exiting into the nose under endoscopic observation. If the inferior turbinate is impacted with the nasal floor, it may be impossible to find the probe under the inferior turbinate without endoscopic control. Finally, during lacrimal duct probing in infants, one can check whether the probe is correctly sited. Perforations created by probing can be recognized and avoided.

Dacryocystorhinostomy↗
PubMed2004

Pressure ulcer risk in hip fracture patients.

Hip fracture patients have a high risk of pressure ulcers (PU). We followed 121 hip fracture patients for the development of pressure ulcers and evaluated a risk assessment tool for sensitivity and specificity. More than half of the patients presented with PU, mostly stage I. Risk factors for PU were high age and the length of time on the operating table. The risk assessment tool had a low predictive value, however. It is thus hard to predict which patients will develop PU and which will not. Accordingly, we propose maximum preventive measures against PU for all patients presenting with hip fractures.

Aged↗
PubMed1999

Technical aspects of the percutaneous cervical and lumbar laser-disc-decompression and -nucleotomy.

To achieve optimal results during percutaneous cervical and lumbar laser-disc-decompression, technical aspects have to be taken into consideration for this minimally invasive operation. The selection of the laser system is thus most significant. A Neodym-YAG-Laser is applied with a wavelength of 1064 nm which, compared to vaporization, has the prerequisites for shrinking from the experimental viewpoint. Selection of parameters for the application of energy depends on size and position of the cervical and lumbar discs. A needle with a mandrin having an outer cross section of up to 2 mm is used to puncture the disc. An ultrasharp needle tip is important. The approach depends on the section of the vertebral column involved. The insertion of the needle in the cervical discs is from the right side ventral and dorsolateral in thoracic and lumbar regions. In difficult cases of spondylophytes the insertion is helped by the so-called punctual laserosteotomy through the spondylophytes, which does not require any additional equipment at the operating table. The C-bow is sufficient for X-ray equipment and has to be adjusted according to the disc position. This minimal invasive procedure shows a technical failure rate of only 1.5/1000 in 2535 percutaneous laser disc decompressions and nucleotomies. There are two malfunctions of the laser machine and one of the X-ray technique. The PLDN using Nd-YAG 1064 nm is a technically perfect method with a very high standard of safety.

Cervical Vertebrae↗
PubMed2006

Ureteroscopic treatment of proximal ureter stones with the aid of an antegrade occlusion balloon catheter.

PURPOSE: To define the role of an antegrade occlusion balloon catheter in preventing migration of proximal ureteral stones to the dilated proximal ureter during endoscopic treatment. MATERIAL AND METHODS: An occlusion balloon catheter was used in 8 of 21 patients with proximal ureteral stones who underwent ureterorenoscopy. Five of the eight patients had solitary kidneys admitting with anuria and had percutaneous nephrostomy. In the other three patients, percutaneous nephrostomy and occlusion balloon catheters were placed a day before the procedure, since these patients had total obstruction and massive dilatation of the proximal ureter and renal collecting system. The balloons of occlusion catheters were inflated with 1 ml of sterile saline proximal to the stones just before ureterorenoscopy. RESULTS: All stones could be reached by ureterorenoscopy and treated successfully with the aid of an ultrasonic lithotripter, and no stone migration to the upper dilated collecting system was observed. Just after the operation, while the patient was still lying on the operation table, the occlusion catheter was removed. The nephrostomy catheter was removed a day later. All patients were totally stone-free after the procedures. CONCLUSION: Occlusion balloon catheters increase the ureteroscopic treatment success rate in proximal ureter stones. This should be kept in mind especially when dilatation of the proximal collecting system is prominent and in cases with unsuccessful previous intervention with a retrograde stone cone catheter.

Adult↗
PubMed1999

Blunt injuries of the stomach.

OBJECTIVE: To evaluate the results of surgical treatment of patients with blunt injuries of the stomach. DESIGN: Retrospective study. SETTING: Two general hospitals, Greece. SUBJECTS: 10 patients operated on for blunt trauma to the stomach during a 10 year period. MAIN OUTCOME MEASURES: Hospital mortality and morbidity. RESULTS: All patients were victims of motor vehicle accidents and presented with clinical signs warranting early laparotomy. There were 6 full-thickness, and 2 partial thickness gastric injuries located in the anterior wall. All injuries could be managed with simple surgical techniques without resections. Two patients bled to death on the operating table from associated injuries. All but one of the survivors had postoperative complications with a mean (SD) duration of hospital stay of 18(8) days (range 10-30). CONCLUSIONS: Blunt gastric injury is usually diagnosed at laparotomy for associated injuries but may occasionally be suspected from specific clinical findings. In most cases the injury is on the anterior wall. Simple repair is usually sufficient and the prognosis depends on the severity of the associated injuries.

Adolescent↗
PubMed2004

Ergonomic problems encountered during video-assisted thoracic surgery.

In laparoscopic surgery, the way of thinking about operating room design is beginning to include ergonomic requirements. No study has yet been published about ergonomic concerns in Video-Assisted Thoracic Surgery (VATS). The aim of this paper is to describe ergonomic issues encountered in VATS and to propose recommendations for operating room design for thoracoscopic surgery. To obtain an inventory of the ergonomic problems fifteen thoracoscopic operations were attended at the Institut Mutualiste Montsouris (Paris, France). Ergonomics can be divided into three divisions: physical, perceptual and cognitive ergonomics. During the observations of thoracoscopic operations the physical problems were registered. The perceptual and cognitive problems were obtained from a literature study. In general two different positions of the surgeon can be distinguished, depending on the placement of the trocars and the endoscope. One position resembles the body position during laparoscopy, involving the same problems such as fatigue of the legs, a static body position, a large working area, extreme movements of the upper limbs and the wrist and stiffness of the neck. The other position is specific for VATS resulting in a rotated upper body while the surgeon has to lean over the patient to be able to handle the instruments. This awkward position causes even more serious problems. The study resulted in a list of ergonomic problems encountered during VATS. Reorganisation of the operating room set-up and monitor position, design of a dedicated operating table and specific instruments might help to overcome the current ergonomic problems.

Journal Article↗
PubMed2005

The frontal pelvic plane provides a valid reference system for implantation of the acetabular cup: spatial orientation of the pelvis in different positions.

BACKGROUND: The frontal pelvic plane has traditionally served as the reference plane for implantation of the acetabular cup during total hip arthroplasty, with referencing performed with the patient supine on the operating table. During daily activities in an upright position, the frontal pelvic plane changes from a horizontal to a vertical orientation. If this change in orientation is accompanied by a substantial change in pelvic inclination angle, it would mean that the use of the frontal pelvic plane as a reference plane for implantation of the acetabular cup would not be valid for proper alignment of the cup. To evaluate this possibility, we measured the change of inclination of the pelvis from the supine to the standing position. SUBJECTS AND METHODS: We evaluated 120 patients, first positioned in a standing position and then supine on a table. Three pelvic landmarks were digitized percutaneously, and the spatial coordinates were calculated with regard to pelvic orientation in the horizontal and the vertical plane. RESULTS: We found a mean inclination of 6.7 degrees in the standing position and 5.6 degrees in the supine position. Patients who were more than 60 years of age who did not have coxarthrosis had a greater inclination angle (8.7 degrees ) while standing. Pelvic orientation was stable with regard to the supine and standing positions. These results were independent of sex, level of arthrosis, or status after implantation of a total hip replacement. INTERPRETATION: The frontal pelvic plane is a valid reference plane for implantation of the acetabular cup.

Acetabulum↗
PubMed2004

On the question of 3D seed reconstruction in prostate brachytherapy: the determination of x-ray source and film locations.

Inaccuracy in seed placement during permanent prostate implants may lead to significant dosimetric deviations from the intended plan. In two recent publications (Todor et al 2002 Phys. Med. Biol. 47 2031-48, Todor et al 2003 Phys. Med. Biol. 48 1153-71), methodology was described for identifying intraoperatively the positions of seeds already implanted, thus allowing reoptimization of the treatment plan and correcting for such seed misplacement. Seed reconstruction is performed using fluoroscopic images and an important (and non-trivial) component of this approach is the ability to accurately determine the position of the gantry relative to the treatment volume. We describe the methodology for acquiring this information, based on the known geometry of six markers attached to the ultrasound probe. This method does not require the C-arm unit to be isocentric and films can be taken with the gantry set at any arbitrary position. This is significant because the patient positioning on the operating table (in the lithotomy position) restricts the range of angles at which films can be taken to a quite narrow (typically +/- 10 degrees) interval and, as a general rule, the closer the angles the larger the uncertainty in the seed location reconstruction along the direction from the x-ray source to the film.

Algorithms↗
PubMed2006

Simultaneous determination of equivalent dose to organs and tissues of the patient and of the physician in interventional radiology using the Monte Carlo method.

This study presents the results of computations of organ equivalent doses and effective doses for the patient and the primary physician during an interventional cardiological examination. The simulations were carried out for seven x-ray spectra (between 60 kVp and 120 kVp) using the Monte Carlo code MCNP. The voxel-based whole-body model VIP-Man was employed to represent both the patient and the physician, the former lying on the operation table while the latter standing 15 cm from the patient at about waist level behind a lead apron. The x-rays, which were generated by a point source positioned around the table and were directed with a conical distribution, irradiated the patient's heart under five major projections used in a coronary angiography examination. The mean effective doses under LAO45, PA, RAO30, LAO45/CAUD30 and LLAT irradiation conditions were calculated as 0.092, 0.163, 0.161, 0.133 and 0.118 mSv/(Gy cm2) for the patient and 1.153, 0.159, 0.145, 0.164 and 0.027 microSv/(Gy cm2) for the shielded physician. The effective doses for the patient determined in this study were usually lower than the literature data obtained through measurements and/or calculations and the discrepancies could be attributed to the fact that this study computes the effective doses specific to the VIP-Man body model, which lacks an ovarian contribution to the gonadal equivalent dose. The effective doses for the physician agreed reasonably well with the literature data.

Adult↗
PubMed2002

Lateral decubitus position for percutaneous nephrolithotripsy in the morbidly obese or kyphotic patient.

BACKGROUND AND PURPOSE: Morbidly obese or debilitated patients do not tolerate the prone position used for percutaneous nephrolithotripsy (PCNL) well and may suffer from severe cardiorespiratory compromise in this position. The purpose of this study is to demonstrate a simple way to overcome this difficulty. PATIENTS AND METHODS: Two morbidly obese patients, ages 48 and 32 years, with Body Mass Indices of 47.5 and 43.2 and a 68-year old patient severely debilitated by multiple cerebral infarctions, ischemic heart disease, and kyphosis suffered from relatively high renal stone burdens. For PCNL, the patients were placed in the lateral decubitus position. To obtain an anteroposterior projection in this position, the C-arm fluoroscopy unit was tilted to one side and the operating table to the other. Tract dilation, stone fragmentation, and fragment extraction were performed with the patient in this position. RESULTS: An attempt to perform PCNL in the prone position in the first patient was aborted because of severe hypoxemia and hypercarbia. In the lateral decubitus position, the procedures were easily performed in all patients without any complications. It was noted that by rotating the C-arm to a perpendicular position, it was possible to perform nephroscopy and use fluoroscopy simultaneously. CONCLUSION: We highly recommend using the lateral position for PCNL in morbidly obese patients and in patients suffering from kyphosis. This position is safe and convenient.

Adult↗
PubMed2003

Surgical skill facilitation in videoscopic open surgery.

The operating room (OR) was traditionally characterized as a closed environment, in which the view of the operative field was available to the surgeon and assistant only. In laparoscopy, integration of technology into the surgical theatre has transformed surgical procedures into minimally invasive events, with viewing of the surgical field using endoscopic cameras. Similar technical advances to the open surgical environment will allow visualization and coordination of finer surgical maneuvers on standard video monitors. The objective of this study was to develop optimal protocols for performing basic open surgical maneuvers without direct viewing of the operating field, instead watching a monitor that displays the image of the surgical field captured by an endoscopic camera. The AESOP robotic arm and Alpha Virtual Port (Computer Motion, Goleta, California) were used to hold the endoscopic camera in different positions relative to the surgeon and the operative table. The surgeons conducting the study evaluated six such different setups. Based on the average time to complete the task in each of these setups and the ease of adaptation to the new working conditions, we concluded that at least one of these setups could be translated into the OR. The advantages of integrating video image enhancement over classical open surgery (OS) are that the surgical field can be magnified to perform finer maneuvers, and to share views of the surgical field with additional clinicians and trainees.

Clinical Competence↗