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PubMed2003

[Programme to introduce and develop minor out-patient surgery in primary care].

INTRODUCTION: Despite the priority placed on it, minor surgery is not performed enough in primary care (PC). OBJECTIVE: To create and evaluate a programme to introduce and develop minor out-patient surgery in primary care in a way that matches our health areas needs. DESIGN: Prospective, longitudinal and descriptive study. SETTING: Health Area 19 (Valencian Health Service): Surgery Department of Elche Hospital and 3 health centres (HC) (Altabix, Crevillente and Santa Pola). PARTICIPANTS: PC doctors and specialist surgeons. STAGES: a) Selection of HC. Working out protocol of kind of patient, pathology, paper-work and establishment of work circuits; b) surgical sessions at the HC, performed by two surgeons assisted by PC doctors (surgical leaders) and with surgical instruments from the hospital; c) surgery performed by PC doctors supervised by a surgeon, with instruments and the sterilisation circuit in the HC. The programme ends up with the PC doctors surgical autonomy and with use of the HCs own resources. RESULTS: 41 surgical sessions took place (14 in Altabix, 14 in Crevillente and 13 in Santa Pola). 335 patients were operated on in 398 surgical procedures (55.5% excisions, 34.9% electrocoagulation, 9.6% others). There were no immediate complications. The monthly evolution in the number of patients was constant, with a mean of 10.22 interventions per session. 36 doctors referred patients and 24 of them performed a surgical procedure. CONCLUSIONS: A practical and safe programme to introduce and develop minor surgery in PC, to the satisfaction of doctors and patients.

Ambulatory Surgical Procedures↗
PubMed1994

Extraperitoneal endoscopic gasless pelvic lymph node dissection.

The insufflated extraperitoneal approach to endoscopic pelvic lymph node dissection has been described as an alternative method of staging carcinoma of the prostate. There are several potential pitfalls in performing this approach, including the use of endoscopic instrumentation, trocars, insufflation equipment, and general anesthesia. In order to overcome potential problems associated with this surgical approach, a totally gasless extraperitoneal approach has been developed. This technique uses standard surgical instruments, does not use carbon dioxide to maintain the operative space, and uses general anesthesia. This procedure is more cost effective, since it uses no special instrumentation except the laprolift and laprofan to maintain the extraperitoneal cavity during lymph node dissection.

Adenocarcinoma↗
PubMed2003

A navigated mechatronic system with haptic features to assist in surgical interventions.

OBJECTIVE: In orthopaedic surgery, the development of new computer-based technologies such as navigation systems and robotics will facilitate more precise, reproducible results in surgical interventions. There are already commercial systems available for clinical use, though these still have some limitations and drawbacks. This paper presents an alternative approach to a universal modular surgical assistant system for supporting less or minimally invasive surgery. MATERIALS AND METHODS: The position of a mechatronic arm, which is part of the system, is controlled by a navigation system so that small patient movements are automatically detected and compensated for in real time. Thus, the optimal tool position can be constantly maintained without the need for rigid bone or patient fixation. Furthermore, a force control mode of the mechatronic assistant system, based on a force-torque sensor, not only increases safety during surgical interventions but also facilitates hand-driven direct positioning of the arm. RESULTS: A prototype has been successfully tested in clinical applications at the Orthopadische Universitätsklinik Frankfurt. For the first time worldwide, implantation of the cup prosthesis in total hip replacement surgery has been carried out with the assistance of a mechatronic arm. According to measurements by the digitizing system, operating tool angle deviation remained below 0.5 degrees, relative to the preoperative planning. CONCLUSION: The presented approach to a new kind of surgical mechatronic assistance system supports the surgeon as needed by optimal positioning of the surgical instruments. Due to its modular design, it is applicable to a wide range of tasks in surgical interventions, e.g., endoscope guidance, bone preparation, etc.

Arthroplasty, Replacement, Hip↗
PubMed2001

[Short- and longterm results after surgical treatment of teat stenosis in the region of Fürstenberg's rosette using theloresectoscopy: 15 cases (1999-2000)].

Teat obstructions cause considerable financial loss in dairy industry. Recently, progress in teat surgery was made by the use of minimal invasive surgical instrumentation. The technique of theloresectoscopy as well as short- and long-term results of this surgical intervention are presented in this study. The clinical reports of 15 dairy cows with distal teat obstructions operated with the theloresectoscope between May 1999 and January 2000 at the clinic for ruminants, Department of clinical veterinary medicine, University of Berne were reviewed. Data collected by telephone conversation with the owners included: somatic cell count and milk flow at machine milking during the lactation of surgery (lactation 1), as well as during the lactation following surgery (lactation 2). Eighty-seven percent of the owners reported normal milk flow during lactation 1 and 93% during lactation 2. Considering the fact that only 46.7% of the cows showed negative results in the California mastitis test (CMT) during lactation 1, many owners reported a high somatic cell count being a disadvantage of this surgical technique. Normal (negative) CMT results during lactation 2, however, were reported by 80% of the owners. Isolation of Staphylococcus aureus explained the high somatic cell count in 2 of 15 cases. In conclusion, theloresectoscopy is a valuable minimal invasive surgical technique that can be fully recommended for treatment of distal teat obstructions in dairy cows.

Animals↗
PubMed2005

Intuitive intraoperative ultrasound guidance using the Sonic Flashlight: a novel ultrasound display system.

OBJECTIVE: The Sonic Flashlight (SF) is a new handheld ultrasound (US) display device being developed at our institution. It replaces the standard monitor on a conventional ultrasound (CUS) system with a miniature monitor and half-silvered mirror to reflect real-time US images into the body. With the SF, the imaged body part appears translucent, with the US image appearing to float below the surface of the anatomy, exactly where it is being scanned. The SF merges the patient, US image, instrument, and operator's hands into the same field of view, allowing the user to operate directly on the US image using normal hand-eye coordination. In contrast, CUS procedures result in displaced hand-eye coordination when the operator looks away from the patient to view the CUS monitor. Intraoperatively, the SF may make localizing and accessing tumors, foreign bodies, hematomas, vascular malformations, and ventricles easier and more accurate, especially for those without extensive CUS training. METHODS: In this cadaver study, the SF was used to visualize the brain and guide a needle into an implanted simulated tumor. The needle was inserted both in the US plane and outside of the US plane. INSTRUMENTATION: Sonic Flashlight fifth generation research prototype. CONCLUSION: The needle was easily and intuitively visualized and guided into the lesion, both within and outside of the US plane. By having the US image appear directly beneath the brain surface, the surgeon can easily and quickly guide the needle or surgical instrument to the lesion. The operator's eyes never have to leave the surgical field, as they do with CUS technology. The impact of this device on neurosurgical procedures could be significant. The ease of use, intuitive function, and small instrument size allow the surgeon to quickly localize lesions, confirm surgical positioning, and assess postoperative results.

Brain Neoplasms↗
PubMed1998

A theoretical comparison of 2-camera and 3-camera optical localizers with active or passive instrumentation.

Since the technology was first pioneered in the medical arena in the early 1990s, optical localizers have increasingly been used in computer assisted surgical procedures. This surgical practice is commonly referred to as "Image Guided Surgery (IGS)". Historically, mechanical stereotactical frames have been used for 3-D position measurement in surgery. Now, new computer input devices can generate high speed numeric position data for direct input into a host computer. This enables application software to acquire the real-time position of surgical instruments and display the positions relative to previously acquired Computer Tomography (CT) or Magnetic Resonance (MR) images on the same computer screen. In addition to optical, there are currently three other types of technologies utilized in the design of these localizers--mechanical, magnetic and sonic. Of these four technologies, optical has emerged as the leader due to its superior accuracy, ease of use, and unobtrusive design. This document focuses on optical localizer technology, specifically comparing 2-camera, or 2-sensor, systems with 3-camera, or 3-sensor, systems. Figures 1 and 2 show applications of such IGS workstations in cranial surgery.

Equipment Design↗
PubMed2005

Tools of the trade.

An unhurried, deft, economical technique allied to efficient use of available resources, surgical instruments and support staff is the hallmark of a 'good' surgeon. To achieve this sense of fluency, surgeons need to be familiar with the tools of their profession so that these can be employed appropriately for the task at hand. The range of instruments available in obstetrics and gynaecology is no less wide or complex than in any other branch of surgery, but formal teaching in the full range of surgical hardware is frequently lacking and an individual's exposure is generally limited to the instruments used in his or her own training hospital. This chapter sets out to describe key technical areas with which surgeons need to be familiar.

Electrosurgery↗
PubMed2006

Clinical anatomy and surgical skills training (CASST): development of a multicenter, multidisciplinary program.

OBJECTIVE: The aim of this program was to develop a multicenter, multidisciplinary anatomy and surgical skills training program for junior residents in obstetrics and gynecology and urology. STUDY DESIGN: After administering a needs assessment, we developed a collaborative clinical anatomy and surgical skills training program for junior residents in obstetrics and gynecology and urology at 3 academic medical centers in Chicago. RESULTS: Thirty-two residents participated in the program. Needs assessment results indicated that all residents felt they could benefit by more formal training in basic surgical skills. Learning objectives were developed for each of the 5 3-hour sessions that dealt with basic surgical skills, anterior abdominal wall anatomy, opening and closing the abdomen, female pelvic anatomy, and perineal anatomy and laceration repair. The cost of training each of the residents was approximately 600 dollars. Forty-five percent of the costs were one-time "start-up" costs for abdominal trainers and surgical instruments. CONCLUSION: By including multiple centers and disciplines, we were able to reduce costs of teaching basic surgical skills and anatomy and maximize faculty teaching time and effort.

Abdomen↗
PubMed2000

The versatile contact Nd:YAG laser in head and neck surgery: an in vivo and clinical analysis.

OBJECTIVE: Lasers have been used in otolaryngology as a surgical instrument for more than 25 years, and the CO2 laser has emerged as the most widely employed surgical laser in use today. However, recent technological advances have made the Nd:YAG laser a challenger as an effective photothermal surgical tool. STUDY DESIGN AND METHODS: This is a two-part study. Tissue injury and healing profiles after application of both the CO2 and Nd:YAG lasers are compared using an in vivo rat tongue model. A prospective clinical review based on the experience of 327 operative cases spanning a 7-year interval using the Nd:YAG laser, highlighting its various applications and associated complications, is detailed. RESULTS: Comparable tissue and healing effects were noted with both lasers in the in vivo rat tongue model with no statistical differences. The clinical application of the laser showed wide versatility in the head and neck with a complication rate of 3%. CONCLUSION: The Nd:YAG laser has proved equivalent in tissue damage and healing to the CO2 laser. The Nd:YAG laser has proved itself to be an excellent and perhaps superior laser for use in head and neck surgery.

Animals↗
PubMed2000

LaminOss immediate-load implants: II. Clinical considerations of osteocompression.

The sinusoidal thread design of the LaminOss (Impladent Ltd, Holliswood, NY) osteocompressive immediate-load implant is structured with minimal shear interface to function in horizontal planes and stimulate bone growth by the action of streaming potentials at the implant thread surface area. This implant design, when used with a unique surgical instrumentation technique, allows maximum bone to be molded and compacted circumferentially around the sinusoidal implant threads. The surgical technique of bone lamination around larger implant horizontal planes (or load-bearing areas) creates a stable foundation for placing this implant into immediate function. For the past 10 years this surgical procedure has provided patients with immediate function the day of implant placement. The clinical advantage of immediate implant loading enhances care acceptance and patient satisfaction.

Bite Force↗
PubMedDate not supplied

[Reconstructive methods in the treatment of soft tissue defects below the knee].

The specificity of the lower leg is in sparse collateral blood flow of the skin cover in the middle and distal part, reduced subcutaneous tissue and the prominence of the front side of tibia immediately under the skin. These characteristics of the lower leg make the application of the standard plastic reconstructive principles, which have been applied in the other regions of the body to a certain degree impossible. The progress of anatomical knowledge in relation to vascularization of the tissue territories--angiosoma, and the anatomy of the vascular skin system of the lower leg, along with the technological progress represented by the application of the surgical microscope, new surgical instruments and suture materials, provides the reconstructive surgeon, not only with classic but also with the modern surgical methods in this region: microvascular transplantation of the tissue and the application of the fasciocutaneous reversible flaps. The aim of this study was to show the available reconstructive methods in the treatment of the lower leg soft tissue and to analyze its application in the management of war wounds in the injured from the civil war in the former Yugoslavia. On the basis of our experiences in the management of war wounds, especially of the lower leg with the tissue defects, we would like to point on the existence of the clear indications for the application of certain reconstructive methods depending on the size, localization and tissue defect structure, as well as the advantages and disadvantages of the available reconstructive procedures.

Humans↗
PubMed1998

Optical coherence tomography for neurosurgical imaging of human intracortical melanoma.

OBJECTIVE: Intraoperative identification of brain tumors and tumor margins has been limited by either the resolution of the in vivo imaging technique or the time required to obtain histological specimens. Our objective was to evaluate the feasibility of using optical coherence tomography (OCT) as a high-resolution, real-time intraoperative imaging technique to identify an intracortical melanoma. INSTRUMENTATION: OCT is a new, noncontact, high-speed imaging technology capable of resolutions on the micrometer scale. OCT is analogous to ultrasound B-mode imaging, except that reflections of infrared light, rather than sound, are detected. OCT uses inherent tissue contrast, rather than enhancement with dyes, to differentiate tissue types. The compact, fiberoptic-based design is readily integrated with surgical instruments. METHODS: A portable handheld OCT surgical imaging probe has been constructed for imaging within the surgical field. Cadaveric human cortex with metastatic melanoma was harvested and imaged in two and three dimensions. Changes in optical backscatter intensity were used to identify regions of tumor and to locate tumor margins. Structures within the optical coherence tomographic images were compared with the histological slides. RESULTS: Two-dimensional images showed increased optical backscatter from regions of tumor, which was quantitatively used to determine the tumor margin. The images correlated well with the histological findings. Three-dimensional reconstructions revealed regions of tumor penetrating normal cortex and could be resectioned at arbitrary planes. Subsurface cerebral vascular structures could be identified and were therefore avoided. CONCLUSION: OCT can effectively differentiate normal cortex from intracortical melanoma based on variations in optical backscatter. The high-resolution, high-speed imaging capabilities of OCT may permit the intraoperative identification of tumor and the more precise localization of tumor margins.

Brain Neoplasms↗
PubMed2005

Advances in imaging of the paranasal sinuses.

Significant changes in surgical technique, surgical instrumentation, and imaging technology have occurred during the past 20 years. These changes have largely resulted from a better understanding of the pathophysiology ofa specific pathologic process, the inflammation of paranasal sinus mucosa. As surgical techniques were adapted to address clinical issues, new instrumentation was developed. Changes in imaging technology were also a result of these and similar issues pressing from other similar medical/surgical fields. The obsolescence of plain-film imaging is being addressed by miniaturization of large and bulky cross-sectional imaging equipment that will gradually become available and embraced by the clinical practice. These changes will bring about greater responsibilities, the foremost of which is vigilance in reducing radiation dose to the patient.

Humans↗
PubMed2001

Novel magnetic technology for intraoperative intracranial frameless navigation: in vivo and in vitro results.

OBJECTIVE: To characterize the accuracy of the Magellan electromagnetic navigation system (Biosense Webster, Tirat HaCarmel, Israel) and to demonstrate the feasibility of its use in image-guided neurosurgical applications. DESCRIPTION OF INSTRUMENTATION: The Magellan system was developed to provide real-time tracking of the distal tips of flexible catheters, steerable endoscopes, and other surgical instruments, using ultra-low electromagnetic fields and a novel miniature position sensor for image-correlated intraoperative navigation and mapping applications. METHODS: An image registration procedure was performed, and static and qualitative accuracies were assessed in a series of phantom, animal, and human neurosurgical studies. EXPERIENCE AND RESULTS: During the human study phase, an accuracy error of up to 5 mm was deemed acceptable. Results demonstrated that this degree of accuracy was maintained throughout all procedures. All anatomic landmarks were reached with precision and were accurately viewed on the display screen. Navigation that relied on the system was also successful. No interference with operating room equipment was noted. The accuracy of the system was maintained during regular surgical procedures, using standard surgical tools. CONCLUSION: The system provides precise lesion localization without limiting the line of vision, the mobility of the surgeon, or the flexibility of instruments. Electromagnetic navigation promises new advances in neuronavigation and frameless stereotactic surgery.

Animals↗
PubMed2000

Vitreous surgery simulator.

OBJECTIVE: To reduce the surgical risks to patients and expose surgeons to surgical experience and complications, we have developed a practical system of vitreous surgery using virtual-reality technology. METHODS: The system is composed of high-resolution color stereo binoculars, haptic devices, foot switches, and a high-speed graphics computer. To simulate vitreous surgery, we created several virtual patient eyes with retinal diseases such as preretinal membranes and subretinal neovascular tissue at the fovea. RESULTS: The simulator provided the trainees with an operating environment similar to an actual one, and allowed them to learn to maneuver surgical instruments and remove proliferative tissue on the retina, under the retina, or both. This system allowed surgeons to avoid iatrogenic complications through visual signs such as retinal hemorrhage when the instrument contacted the retinal surface. CONCLUSIONS: This simulator may not only be suitable for residents to learn ocular surgical techniques but may also allow veteran surgeons to develop new surgical methods and skills.

Computer Simulation↗
PubMed2000

Hand-assisted laparoscopic aortobifemoral bypass grafting.

OBJECTIVE: Aortobifemoral bypass grafting is a durable operation for arterial reconstruction in patients with symptomatic aortoiliac occlusive disease. In several small laparoscopic series technically demanding aortic operations have been described that have not gained widespread acceptance or applicability. To simplify the laparoscopic approach to the aorta, we have developed a technique of aortobifemoral bypass grafting that uses hand-assisted laparoscopic surgery (HALS) to minimize the complexity of aortic dissection and reconstruction. METHODS: Five patients with symptomatic aortoiliac occlusive disease underwent successful HALS aortobifemoral bypass grafting. With the use of a specialized sleeve device (Hand-Port), an operative hand was introduced into the laparoscopic field while pneumoperitoneum was maintained. Laparoscopic dissection of the infrarenal aorta was then performed with retraction provided by the operative hand. Proximal aortic anastomosis was performed with an open technique through the same 7.5-cm Hand-Port incision, and femoral anastomoses were performed in the standard fashion. RESULTS: Five hand-assisted laparoscopic aortobifemoral bypass grafts were performed (two end-to-end, three end-to-side proximal anastomoses). Mean operative time was 231 minutes. Mean blood loss was 440 mL. All patients underwent extubation immediately after surgery, were ambulatory on postoperative day (POD) 1, and were tolerating their diet by POD 3. The mean length of hospital stay was 3.8 days. One patient was discharged on POD 5 and started a clear liquid diet after a self-limiting postoperative ileus. All patients were asymptomatic and back to full activity/work by 14.6 days postoperatively, on average (range, 11-20 days). CONCLUSION: The HALS offers the advantages of tactile feedback, flexible retraction, and the introduction of conventional surgical instruments, all of which extend laparoscopic surgery and its established benefits to a wide array of more complex surgical problems, including major vascular surgery. Ease of performance, shorter hospital stays, and faster recovery times all suggest that HALS may become a valuable adjunct to conventional aortobifemoral bypass grafting.

Adult↗
PubMed2001

Spinal cord and nerve root monitoring during surgical treatment of lumbar stenosis.

The author describes application of intraoperative neurophysiologic monitoring to surgical treatment of lumbar stenosis. Benefits of somatosensory and motor evoked potential studies during surgical correction of spinal deformity are well known and documented. Free-running and evoked electromyographic studies during pedicle screw implantation is an accepted practice at many institutions. However, the functional integrity of spinal cord, cauda equina, and nerve roots should be monitored throughout every stage of surgery including exposure and decompression. Somatosensory evoked potentials monitor overall spinal cord function. Intraoperative electromyography provides continuous assessment of motor root function in response to direct and indirect surgical manipulation. Electromyographic activities observed during exposure and decompression of the lumbosacral spine included complex patterns of bursting and neurotonic discharge. In addition, electromyographic activities at distal musculature were elicited by impacting a surgical instrument or graft plug against bony elements of the spine. All electromyographic events provided direct feedback to the surgical team and were regarded as a cause for concern. Simultaneously monitored evoked potential and electromyographic studies protect spinal cord and nerve roots during seemingly low-risk phases of a surgical procedure when neurologic injury may occur and the patient is placed at risk for postoperative myelopathy or radiculopathy.

Decompression, Surgical↗