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At least 703 records · Page 39Linked to original sources
PubMed1998

Stereotactic mechanical percutaneous renal access.

Obtaining accurate percutaneous renal access when treating intrarenal disease requires substantial skill. Robotic devices have been used in a variety of surgical applications and have been successful in facilitating percutaneous puncture while improving accuracy. Laboratory models of robotic devices for percutaneous renal access have also been developed. However, several technical hurdles need to be addressed. One relates to the device-patient interface. As a first step in creating a complete robotic system, a mechanical arm (PAKY) with active translational motion for percutaneous renal access has been developed and clinically assessed. The PAKY consists of a passive mechanical arm mounted on the operating table and a radiolucent needle driver that uses a novel active translational mechanism for needle advancement. The system utilizes real-time fluoroscopic images provided by a C-arm to align and monitor active needle placement. In vitro experiments to test needle placement accuracy were conducted using a porcine kidney suspended in agarose gel. Seven copper balls 3 to 12.5 mm diameter were placed in the collecting system as targets, and successful access was confirmed by electrical contact with the ball. The PAKY was then used clinically in nine patients. The number of attempts, target calix location, calix size, and time elapsed were evaluated. In the in vitro study, successful needle-ball contact occurred the first time in all 70 attempts, including 10 attempts at the 3-mm balls. Clinically, percutaneous access to the desired calix was attained on the first attempt in each case. The mean target calix diameter was 14.7 mm (range 7-40 mm). The mean time elapsed while attempting access was 8.2 minutes. No perioperative complications attributable to needle access occurred. Early experience indicates that the PAKY provides a steady needle holder and an effective and safe end-effector for percutaneous renal access. This device may provide the mechanical platform for the development of a complete robotic system capable of creating percutaneous renal access.

Adult↗
PubMed1994

Planned laparoscopic repair of a spigelian hernia using a composite prosthesis.

A planned elective repair, via the laparoscope, of a spigelian hernia is described. The repair was performed using a composite mesh prosthesis consisting of a sandwich of polyester fiber mesh and polyglactin 910 mesh, sutured together with polyglactin 910 suture at the operating table before introduction. The technique is applicable to other hernias of the anterior abdominal wall.

Adult↗
PubMed1980

Effect of baricity on spinal anaesthesia with amethocaine.

Amethocaine 1% solution was mixed with equal volumes of water, 0.9% saline or 10% dextrose to prepare respectively, hypobaric, isobaric and hyperbaric solutions which were compared for intradural spinal anaesthesia in 60 patients. Thirty patients received 10 mg and 30 patients received 15 mg of amethocaine. Injections were made with the patients in the lateral recumbent position and the operating table was horizontal during and after injection. Equal numbers of patients and equal numbers of males and females received hypobaric, isobaric and hyperbaric solutions. The mean spread of analgesia after the hyperbaric solution was five dermatomes greater than after the other two solutions, but the extent of analgesia was not significantly different whether amethocaine 10 mg or 15 mg was injected. The mean duration of analgesia after the hyperbaric solution was 285 min compared with 332 min and 360 min after the isobaric and hypobaric solutions respectively. The mean duration of analgesia after amethocaine 15 mg was significantly greater than after 10 mg.

Adult↗
PubMed1983

Haemodynamic effects of induced hypotension with a nitroprusside-trimetaphan mixture.

The haemodynamic effects of a 10:1 mixture of trimetaphan and nitroprusside have been studied before and during the course of surgery, in 12 patients placed in 5 degrees reverse Trendelenburg position. Six patients breathed spontaneously and in six the lungs were ventilated artificially. The mixture had a potent hypotensive action that was almost as rapid in onset and recovery as that produced by nitroprusside alone, but the required dose of each drug was decreased considerably. In patients breathing spontaneously, cardiac output remained unchanged on the induction of hypotension, but it decreased significantly in the IPPV group. Heart rate increased, and stroke volume, peripheral resistance and central venous pressure decreased in both groups. The start of surgery was associated with a need to increase the dose of the hypotensive mixture, and with a further increase in heart rate and decrease in stroke volume. Levelling the operating table produced an increase in cardiac output and discontinuation of the mixture resulted in a rapid return of all measurements towards control values.

Adult↗
PubMed2003

A simple method to pass a pulmonary artery flotation catheter rapidly into the pulmonary artery in anaesthetized patients.

BACKGROUND: In some patients passage of a pulmonary artery flotation catheter (PAFC) into the pulmonary artery may be difficult and time consuming and the prolonged manipulation can cause ventricular arrhythmias. A simple clinical method used during general anaesthesia is presented to allow rapid passage of a PAFC into the pulmonary artery. METHODS: The operating table is positioned head up and slightly right side down to position the pulmonary valve at the highest level possible. When the balloon catheter is in the right ventricular outflow tract (indicated by premature ventricular contractions) the ventilator is paused in inspiration and the balloon catheter simultaneously passed into the pulmonary artery. RESULTS: The manoeuvre shortens the time necessary to pass the catheter into the pulmonary artery and may reduce ventricular arrhythmias. Over 5 yr, 105 PAFCs were inserted with this method without major complications. CONCLUSION: This method may reduce the risk of ventricular arrhythmias, and could be particularly useful in high-risk critically ill patients.

Anesthesia, General↗
PubMed1995

Choices in health care: a contribution from The Netherlands.

In this paper it will be argued that choices in health care are necessary, desirable and just. An important choice that each society has to make, is: what basic services should be available to everybody independently of an individual's purchasing power? The Dutch Government Committee on Choices in Health Care advised the use of four criteria: basic care must be necessary, effective, efficient and cannot be left to the individual's responsibility. Because important decisions with respect to the second criterion-the effectiveness of care-are made by physicians in the consulting room or at the operating table, physicians do have a primary responsibility in making the right choices.

Choice Behavior↗
PubMed2000

The effects of the single or multiple injection technique on the onset time of femoral nerve blocks with 0.75% ropivacaine.

UNLABELLED: We evaluated the effect of the injection technique on the onset time and efficacy of femoral nerve block performed with 0.75% ropivacaine. A total of 30 patients undergoing arthroscopic knee surgery were randomly allocated to receive femoral nerve blockade with 0.75% ropivacaine by using either a single injection (Single group, n = 15) or multiple injection (Multiple group, n = 15). Nerve blocks were placed by using a short-beveled, Teflon-coated, stimulating needle. The stimulation frequency was set at 2 Hz, and the intensity of stimulating current, initially set at 1 mA, was gradually decreased to <0.5 mA after each muscular twitch was observed. In the Single group, 12 mL of 0.75% ropivacaine was slowly injected, as soon as the first muscular twitch was observed. In the Multiple group, the stimulating needle was inserted and redirected, eliciting each of the following muscular twitches: contraction of vastus medialis, vastus intermedius, and vastus lateralis. At each muscular twitch, 4 mL of the study solution was injected. Placing the block required 4.2 +/- 1.7 min (median, 5 min; range, 2-8 min) in the Multiple group and 3.4 +/- 2.2 min (median, 3 min; range, 1-5 min) in the Single group (P = 0.02). Onset of nerve block (complete loss of pinprick sensation in the femoral nerve distribution with concomitant inability to elevate the leg from the operating table with the hip flexed) required 10 +/- 3.7 min in the Multiple group (median, 10 min; range, 5-20 min) and 30 +/- 11 min in the Single group (median, 30 min; range, 10-50 min) (P < 0.0005). Propofol sedation was never required to complete surgery; although 0.1 mg fentanyl at trocar insertion was required in two patients of the Multiple group (13%) and nine patients of the Single group (60%) (P = 0.02). We conclude that searching for multiple muscular twitches shortened the onset time and improved the quality of femoral nerve block performed with small volumes of 0.75% ropivacaine. IMPLICATIONS: This prospective, randomized, blinded study was conducted to evaluate the effect of searching for multiple muscular twitches when performing femoral nerve block with small volumes of 0. 75% ropivacaine. Our results demonstrated that multiple injections markedly shortened the onset time and improved the quality of nerve blockade. This technique-related effect must be carefully considered when different clinical studies evaluating the use of new local anesthetic solutions for peripheral nerve blocks are compared.

Adolescent↗
PubMed1989

Differential effects of pancuronium on masseter and adductor pollicis muscles in humans.

The sensitivity of the masseter, one of the muscles of the upper airway, to pancuronium was measured in ten adults undergoing elective surgery and compared with that of the adductor pollicis. During thiopental-nitrous oxide-enflurane (end-tidal concentration less than 0.25%) anesthesia, supramaximal nerve stimulation was applied to the ulnar nerve at the elbow and to the nerve to the masseter, at a point inferior to the zygomatic arch, anterior to the mandibular condyle. Jaw closure was measured by a force transducer system attached to both an oral airway and a metal frame fixed to the operating table 10 cm caudad to the chin. Cumulative dose-response curves for pancuronium (initial dose = 0.02 mg/kg, incremental doses = 0.01 mg/kg) were determined. Control twitch tensions were (mean +/- SEM) 473 +/- 75 g at the masseter and 660 +/- 118 g at the adductor pollicis. The masseter was slightly more sensitive to pancuronium, the ED50 being 0.024 +/- 0.001 mg/kg compared with 0.028 +/- 0.001 mg/kg for the adductor pollicis (P less than 0.05). Corresponding values for the ED90 were 0.038 +/- 0.004 and 0.043 +/- 0.002 mg/kg, respectively (P less than 0.05). The time from injection of the first dose of pancuronium to maximum blockade was 3.2 +/- 0.2 min at the masseter and 3.8 +/- 0.2 min at the adductor pollicis (P less than 0.01). Following incremental doses, this time was 1.8 +/- 0.1 and 2.6 +/- 0.1 min, respectively (P less than 0.01). It is concluded that after injection of pancuronium, neuromuscular blockade is greater at the masseter and occurs sooner than at the adductor pollicis. Jaw relaxation can be achieved with relatively small doses of pancuronium. This suggests that return of adductor pollicis function may not imply complete masseter muscle recovery.

Adult↗
PubMed1990

Patient variables and the subarachnoid spread of hyperbaric bupivacaine in the term parturient.

To determine if age, height, weight, body mass index, or vertebral column length significantly influence the distribution of sensory analgesia or anesthesia after subarachnoid injection of hyperbaric bupivacaine, 52 women presenting for cesarean section were studied. All received 15 mg hyperbaric bupivacaine via subarachnoid injection at L-2 or L-3. Fifteen minutes after injection, while the women lay supine on a horizontal operating table, the maximum cephalad extent of sensory analgesia (loss of sensation of sharpness to pin prick) and anesthesia (loss of sensation of light touch) was determined. Age (20-42 yr), height (146.9-174.0 cm), weight (55.5-136.4 kg), body mass index (19.2-50.0 kg/m2), and vertebral column length (49.6-67.0 cm) did not correlate with the spread of sensory blockade. In conclusion, in parturients of age, height, weight, body mass index, and vertebral column length within the aforementioned ranges, it is not necessary to vary the dose of injected hyperbaric bupivacaine with changes in any of the patient variables studied.

Adult↗
PubMed1998

Intraoperative awareness in fast-track cardiac anesthesia.

BACKGROUND: Fast-track cardiac anesthesia, using low-dose narcotics combined with short-acting anesthetic and sedative agents, facilitates early tracheal extubation after cardiac surgery. The incidence of awareness with this anesthetic technique has not been investigated previously. The purpose of this study was to prospectively investigate the incidence of intraoperative awareness with explicit memory of events during fast-track cardiac anesthesia. METHODS: Data were collected prospectively over a 4-month period from 617 consecutive adult patients undergoing cardiac surgery at a university hospital. All patients received a fast-track cardiac anesthetic regimen. Patients underwent a structured interview by a research nurse 18 h after extubation. A standard set of questions was asked during this interview to determine if the patient had explicit memory of any event from induction of anesthesia to recovery of consciousness. RESULTS: Nine patients did not complete a postoperative interview because of death (n = 7) or postoperative confusion (n = 2). The last memory before surgery reported in 420 (69.1%) patients was waiting in the holding area at the operating suite, and in the remaining 188 (30.9%) patients it was lying on the operating table before induction of anesthesia. Two patients (0.3%) had explicit memory of intraoperative events. One of the two patients also had explicit memory of pain. Neither patient reported adverse psychological sequelae. CONCLUSIONS: The authors report an incidence of awareness in fast-track cardiac anesthesia of 0.3%. This is the lowest incidence of awareness currently reported during cardiac surgery. This low incidence of awareness may be related to the use of a balanced anesthetic technique involving the continuous administration of volatile (isoflurane) or intravenous (propofol) anesthetic agents before, during, and after cardiopulmonary bypass.

Anesthesia↗
PubMed1999

Ulnar nerve pressure: influence of arm position and relationship to somatosensory evoked potentials.

BACKGROUND: Although the ulnar nerve is the most frequent site of perioperative neuropathy, the mechanism remains undefined. The ulnar nerve appears particularly susceptible to external pressure as it courses through the superficial condylar groove at the elbow, rendering it vulnerable to direct compression and ischemia However, there is disagreement among major anesthesia textbooks regarding optimal positioning of the arm during anesthesia. METHODS: To determine which arm position (supination, neutral orientation, or pronation) minimizes external pressure applied to the ulnar nerve, we studied 50 awake, normal volunteers using a computerized pressure sensing mat. An additional group of 15 subjects was tested on an operating table with their arm in 30 degrees, 60 degrees, and 90 degrees of abduction, as well as in supination, neutral orientation, and pronation. To determine the onset of clinical paresthesia compared to the onset and severity of somatosensory evoked potential (SSEP) electrophysiologic changes, we studied a separate group of 16 male volunteers while applying intentional pressure directly to the ulnar nerve. Data are presented as mean (median; range). RESULTS: Supination minimizes direct pressure over the ulnar nerve at the elbow (2 mmHg [0; 0-23]; n = 50), compared with both neutral forearm orientation (69 mmHg [22; 0-220]; P < 0.0001), as well as pronation (95 mmHg [61; 0-220]; P < 0.0001). Neutral forearm orientation also results in significantly less pressure over the ulnar nerve compared to pronation (P < or = 0.04). The estimated contact area of the ulnar nerve with the weight-bearing surface was significantly (P < 0.0001) smaller in the supine position (2.2 cm2 [0.5; 0-9]; n = 50) compared with both neutral orientation (5.5 cm2 [5.0; 0-13]) and pronation (5.8 cm2 [6; 0-12]). With the forearm in neutral orientation, ulnar nerve pressure decreased significantly (P < or = 0.01; n = 15) as the arm was abducted at the shoulder from 0 degrees to 90 degrees. In the 16 male subjects tested, notable alterations in ulnar nerve SSEP signals (decrease > or = 20% in N9-N9' amplitude) were detected in 15 of 16 awake males during application of intentional pressure to the ulnar nerve. However, eight of these subjects did not perceive a paresthesia, even as SSEP waveform amplitudes were decreasing 23-72%. Two of these eight subjects manifested severe decreases in SSEP amplitude (> or = 60%). CONCLUSIONS: Extrapolating these results to the clinical setting, the supinated arm position is likely to minimize pressure over the ulnar nerve. With the forearm in neutral orientation, pressure over the ulnar nerve decreases as the arm is abducted between 30 degrees and 90 degrees. In addition, up to one half of male patients may fail to perceive or experience clinical symptoms of ulnar nerve compression sufficient to elicit SSEP changes.

Adult↗
PubMed1994

The medial approach to the sural vessels to facilitate microanastomosis about the knee.

Complex wounds about the knee in rare instances may justify the selection of a distant microvascular tissue transfer for coverage. A major preoperative consideration then is the choice of an appropriate recipient site for revascularizing the flap that is outside the zone of injury, and preferably avoids the need for vein grafts. In many cases, the heads of the gastrocnemius muscles have protected the sural vessels from injury, allowing these to be used as a vascular extension of the popliteal system to simplify the required microanastomoses in an end-to-end fashion. Access to the sural vessels can be readily achieved through a medial approach to the popliteal fossa that permits the patient to remain supine or lateral on the operating table for simultaneous exposure of multiple privileged donor sites.

Anastomosis, Surgical↗
PubMed1975

Conservative surgical treatment of reflux esophagitis and esophageal stricture.

During a recent 3-year period, 17 consecutive patients were seen with advanced fibrotic esophageal strictures secondary to alkaline-acid-pepsin reflux. From detailed preoperative evaluations alone it was impossible to determine whether therapy should consist of excisional surgery, esophagogastroplasty or intra-operative dilatation with correction of reflux. Only at operation could the length, extent, degree and severity of the stricture be fully determined. Each of the 17 patients was treated by controlled dilatation, coupled with an antireflux procedure. This simplified approach proved successful on strictures thought preoperatively to be undilatable. It appears that this conservative approach is applicable to many advanced strictures and excisional and plastic procedures should be reserved for those cases that prove unyielding to intraoperative dilatation. The true appraisal of a reflux stricture and the choice of surgical procedure is best determined at the operating table.

Aged↗
PubMed1975

Recurrent ulnar-nerve dislocation at the elbow.

Recurring luxation of the ulnar nerve at the elbow is not uncommon (16.2%), occurring about equally in young and old, male and female, athletes and non-athletes but the greater mobility is usually at the dominant arm. The probable cause of such dislocation is congenital laxity of supporting ligaments. Being more vulnerable to injury than normally-positioned nerves, however, complicating neuritis can does occur. Subluxating nerves which stop on the tip of the medial humeral epicondyle upon 90 degrees or more of flexion at the elbow are more subject to direct trauma than completely displaced neural structures which cross the epicondyle upon elbow flexion. The latter may develop friction neuritis which occurs most frequently in industrial workers and occasionally requires surgical transfer. Deep intramuscular implantation, with or without neurolysis, is definetely superior to subcutaneous placement of the affected nerve. In this report are described chemically-induced ulnar neuritis from cortisone injections about the medial humeral epicondyle; pressure ulnar neuritis in patients with enforced bed rest and from improper positioning on operating table with permanent neural deficit and the relationship of such hypermobile ulnar nerves to extension-flexion (whiplash) trauma to the neck. It is emphasized that most of these complications could have been avoided had the patient and his physician known that such anomalies were present. Of particular importance is the avoidance of pressure to the medial aspect of a flexed elbow in surgical patients under general anesthesia. The unrelated co-existence of intermittently-symptomatic hypermobile ulnar nerves and extension-flexion neck trauma may occur. Recognition of isolated unlar neuritis in these patients is definitely important from the diagnostic, treatment and medical-legal aspects of such cervical spine injuries.

Adult↗
PubMed2002

Perioperative ulnar neuropathy in orthopaedics: association with tilting the patient.

The incidence and causes of perioperative ulnar neuropathy in a prospective series of 203 consecutive patients were examined. Three percent of patients had ulnar neuropathy develop in the entire prospective series. The incidence was 6% in patients having total hip arthroplasty. There was a highly significant association between a tilted body position on the operating table and development of ulnar neuropathy on the contralateral side. This position rotates the arm internally and places the ulnar nerve at risk for direct compression.

Adolescent↗
PubMed1994

The reliability of detecting screw penetration of the acetabulum by intraoperative auscultation.

Open reduction and internal fixation of the acetabulum frequently requires placement of screws in a blind fashion that risks penetrating the joint surface. While in the operative suite, direct visualization of the joint surface may not be possible, and fluoroscopy can be difficult to interpret. Auscultation of the hip with motion in a quiet room has been suggested as a useful adjunct to detecting screw penetration. Carrying that concept further, we auscultate the hip using a sterile esophageal stethoscope at the operating table and have found this to be a highly reliable method of detecting intraarticular screw placement. To test the reliability and reproducibility of this technique, an experiment was performed using inexperienced volunteers. In part I, two adult mongrel dogs were prepared. A screw was placed violating the hip joint in one dog, and in the other dog a screw was placed near but not penetrating the joint. Screw placement was verified under direct vision. Seventy-seven volunteers who did not know which hip was penetrated then auscultated both hips in random order and recorded their impressions after each hip was heard. After hearing both hips, 74 of 77 were able to identify the screw in the hip joint correctly; 69 were able to recognize the extraarticular screw correctly. In part II, both hips of a human cadaver were exposed and dislocated. In one hip, a screw was placed that tangentially violated the joint, and in the same area of the contralateral hip a screw was placed that did not penetrate the joint surface.(ABSTRACT TRUNCATED AT 250 WORDS)

Acetabulum↗
PubMed2000

Rotational alignment of humerus after closed locked nailing.

OBJECTIVE: Rotational malalignment that may happen during closed nailing of humeral fractures is, to date, an unexplored area of investigation. The purpose of this study was to examine the effect of arm position during surgery on humeral rotational alignment and the effect of this alignment on shoulder motion and function. METHODS: Thirty patients with eventual fracture healing after closed humeral locked nailing were retrospectively studied: 15 had retrograde nailing; 15, antegrade. Retrograde nailing was performed with the patient in a decubitus position and with the upper arm anteriorly flexed and the forearm perpendicular to the operating table. Antegrade nailing was performed with the patient in a semisitting position and with the upper arm in the so-called resting position. The humeral retroversion angle as measured by computed tomographic scan, range of shoulder rotation, and Neer score of the shoulder for the fractured and the intact humeri were determined, and the discrepancy (i.e., value for the intact subtracted from that for the fractured) between the two was noted. To test the effect on alignment of positioning during retrograde nailing, we similarly determined retroversion angles for another 15 patients treated in a supine resting position. RESULTS: Between antegrade nailing and retrograde nailing in decubitus position, there was a significant difference in the mean discrepancies for the retroversion angles and the range of external rotation of the shoulder in the neutral and abduction positions, but no significant difference for internal rotation of the shoulder and Neer score. Between antegrade nailing and retrograde nailing in supine resting position, there was no significant difference in the mean discrepancy for the retroversion angle. CONCLUSION: Positioning of the arm may significantly affect humeral rotational alignment and range of motion during closed nailing. Until a reliable method for intraoperative measurement of humeral rotation is devised, we recommend that closed nailing of humeral shaft fractures be performed with the patient's upper arm in the resting position shown in this study.

Adolescent↗
PubMed2002

Renal salvage in penetrating kidney injuries: a prospective analysis.

BACKGROUND: Routine exploration of penetrating kidney injuries is not advised because of the fear of a higher nephrectomy rate. This study was conducted to assess the efficacy of renal salvage in patients who underwent routine exploration of the injured kidney and to document complications related to the procedure. METHODS: This was a prospective study over a 2-year period. RESULTS: Fifty patients (46 male and 4 female patients), median age 29 years (range, 16-69 years), were included. Mechanisms of injury were gunshot wound in 43 patients (86%) and stab wounds in 7 patients (14%). Mean Revised Trauma Score was 10.5. All patients underwent laparotomy. Three injuries were bilateral, for a total of 53 renal units. There were three deaths on the operating table (two nephrectomies and one bilateral repair). Management of the remaining 49 renal units was as follows: simple drainage in 13 (26.5%), renal repair in 17 (35%), partial nephrectomy in 6 (12%), and nephrectomy in 13 (26.5%). There were two minor complications directly related to the renal salvage: transient hypertension in one patient and a urine leak, which settled on conservative management. CONCLUSION: An overall renal salvage rate of 73.5% for penetrating trauma was achieved with routine exploration of the injured kidney.

Adolescent↗