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In Vivo Analysis of Heterogeneous Brain Deformation Computations for Model-Updated Image Guidance.

Neurosurgical image-guidance has historically relied on the registration of the patient and preoperative imaging series with surgical instruments in the operating room (OR) coordinate space. Recent studies measuring intraoperative tissue motion have suggested that deformation-induced misregistration from surgical loading is a serious concern with such systems. In an effort to improve registration fidelity during surgery, we are pursuing an approach which uses a predictive computational model in conjunction with data available in the OR to update the high resolution preoperative image series. In previous work, we have developed an in vivo experimental system in the porcine brain which has been used to investigate a homogeneous finite element rendering of consolidation theory as a tissue deformation model. In this paper, our computational approach has been extended to include heterogeneous tissue property distributions determined from an image-to-grid segmentation scheme. Results produced under two different loading conditions show that heterogeneity in the stiffness properties and interstitial pressure gradients varied over a range of physiologically reasonable values account for 1-3% and 5-8% of the predicted tissue motion, respectively, while homogeneous linear elasticity is responsible for 60-70% of the surgically-induced motion that has been recoverable with our model-based approach.

Journal Article↗

Surgical robotics. Evaluation of the Computer Motion AESOP 3000 robotic endoscope holder.

The use of robots to manipulate surgical instruments inside the patient has already moved from the world of fiction to fact. While the widespread use of full-function surgical robots is still many years away, less sophisticated robots that perform very specific surgical functions are already at a stage where the typical hospital can consider their use. Currently, the most affordable and commonly used type of "surgical-assist" robot is the robotic endoscope holder, which is used to hold and position rigid endoscopes during minimally invasive surgery. In this study, we introduce readers to the topic of surgical robotics, focusing specifically on robotic endoscope holders. The study includes a Technology Management Guide, in which we discuss who should and who shouldn't consider implementing such robots, and it includes our evaluation protocol and findings for one such robot, the Computer Motion AESOP 3000. We judged the evaluated system based on its performance relative to the human scope holders it is designed to replace, as well as its safety and ease of use. While we found the AESOP 3000 to be an acceptable, and sometimes preferred, alternative to the use of a human scope holder, we caution that many healthcare facilities won't see sufficient clinical benefit to warrant its purchase at this time.

Electric Power Supplies↗

Sterilization and disinfection in the physician's office.

OBJECTIVE: To review the principles and practice of sterilization and disinfection of medical instruments in the office setting. DATA SOURCES: Searches of MEDLINE for articles published from 1980 to 1990 on disinfection, sterilization, cross infection, surgical instruments and iatrogenic disease, bibliographies, standard texts and reference material located in a central processing department. STUDY SELECTION: We reviewed surveys of decontamination practices in physicians' offices, reviews of current recommendations for office decontamination procedures, case reports of cross infection in offices and much of the standard reference material on decontamination theory and practice. DATA SYNTHESIS: There have been few surveys of physicians' decontamination practices and few case reports of cross infection. Office practitioners have little access to practical information on sterilization and disinfection. CONCLUSION: The increasing threat of cross infection from medical instruments calls for greater knowledge about decontamination. We have adapted material from various sources and offer a primer on the subject.

Cross Infection↗

Variant Creutzfeldt-Jakob disease and the potential for its accidental transmission following surgery with contaminated instruments: the risk of transmission in Australia.

We present a simple model for the quantitative risk assessment of vCJD transmission following surgery. Factors that affect the transmission of the disease are prevalence of the disease, concentration of prions in tissues, genetic susceptibility, the number and type of surgical procedures and the effectiveness of decontamination procedures. The main sources of uncertainty are the number of people currently incubating vCJD in Australia and the effectiveness of the decontamination processes for surgical instrumentation. The model serves as a guide for predicting the number of possible vCJD transmissions following individual surgical procedures. It is the uncertainty of the epidemic that poses a challenge to the public health scientist. Greater certainty of the pathogenesis and progression of the disease will only come with increased years of surveillance.

Adolescent↗

Management of tumors of the thoracolumbar spine.

Current improvements in radiologic imaging and surgical instrumentation have greatly expanded the role of surgery in management of tumors of the thoracolumbar junction. For primary malignant tumors, the aim of surgery should be curative, with eradiction of all gross disease. For metastatic tumors, indications for surgery include cancer therapy, stabilization, neurologic palliation, tissue diagnosis, and pain relief. Because the thoracolumbar region is a transitional zone, surgical stabilization may require anterior-posterior approaches and instrumentation.

Combined Modality Therapy↗

Possible intraocular lens contamination by surgical glove powder.

Contamination of the operative field by glove powders, even after washing and wiping, is a well-described entity. We present a case of presumed secondary intraocular lens contamination by surgical glove powder. This complication can be avoided by being sure that no intraocular surgical instruments or implants are directly handled by the fingers.

Aged↗

Thumbtack use for control of presacral bleeding, with description of an instrument for thumbtack application.

There is well-known difficulty in controlling hemorrhage from presacral vessels. There are reports on the use of thumbtacks to secure hemostasis in the face of presacral hemorrhage. This communication reports the successful use of thumbtacks to establish presacral hemostasis and describes a simple instrument designed to afford easier and more precise anterior sacral application of thumbtacks. The instrument is easy to make. It was devised because of difficulty encountered with manual placement of hemostatic thumbtacks and the absence of totally satisfactory delivery by any of the standard surgical instruments available.

Blood Vessels↗

Surgical navigation based on fluoroscopy--clinical application for computer-assisted distal locking of intramedullary implants.

OBJECTIVE: Fluoroscopy is used to guide surgical instruments during orthopedic procedures. Radiation exposure and lack of spatial information are drawbacks of this method. Improvements are expected when fluoroscopy-based surgical navigation is used for intraoperative guidance, e.g., in computer-assisted distal locking of intramedullary implants. PATIENTS AND METHODS: The method was applied to 42 interlocking procedures during implantation of the short proximal femoral nail in 27 patients with pertrochanteric femoral fractures. Precision of interlocking, exposure time, operating time, and number of personnel required for computer-assisted distal locking were recorded. RESULTS: One misplaced interlocking screw was observed (2.3%), and contact between the drill bit and the nail during drilling was noticed in 8 cases (19%). The average exposure time was 16 seconds (range 4-42 seconds), and the procedure took an average of 43 min (range 20-70 min). The number of persons required for computer-assisted distal locking was reduced from three to one within the course of the study. CONCLUSIONS: Fluoroscopy-based surgical navigation provided precise intraoperative guidance for computer-assisted distal locking with minimal use of fluoroscopy. The complex system and related procedure times may be drawbacks in this application. Clinical studies are underway to define implants and surgical procedures where intraoperative guidance by fluoroscopy-based surgical navigation is beneficial for the patient and/or surgeon.

Computer Simulation↗

Reliability and performance of innovative surgical double-glove hole puncture indication systems.

During operative procedures, operating room personnel wear sterile surgical gloves designed to protect them and their patients against transmissible infections. The Food and Drug Administration (FDA) has set compliance policy guides for manufacturers of gloves. The FDA allows surgeons' gloves whose leakage defect rates do not exceed 1.5 acceptable quality level (AQL) to be used in operating rooms. The implications of this policy are potentially enormous to operating room personnel and patients. This unacceptable risk to the personnel and patient could be significantly reduced by the use of sterile double surgical gloves. Because double-gloves are also susceptible to needle puncture, a double-glove hole indication system is urgently needed to immediately detect surgical needle glove punctures. This warning would allow surgeons to remove the double-gloves, wash their hands, and then don a sterile set of double-gloves with an indication system. During the last decade, Regent Medical has devised non-latex and latex double-glove hole puncture indication systems. The purpose of this comprehensive study is to detect the accuracy of the non-latex and latex double-glove hole puncture indication systems using five commonly used sterile surgical needles: the taper point surgical needle, tapercut surgical needle, reverse cutting edge surgical needle, taper cardiopoint surgical needle, and spatula surgical needle. After subjecting both the non-latex and latex double-glove hole puncture indication systems to surgical needle puncture in each glove fingertip, these double-glove systems were immersed in a sterile basin of saline, after which the double-gloved hands manipulated surgical instruments. Within two minutes, both the non-latex and latex hole puncture indication systems accurately detected needle punctures in all of the surgical gloves, regardless of the dimensions of the surgical needles. In addition, the size of the color change visualized through the translucent outer glove did not correlate with needle diameter. On the basis of this extensive experimental evaluation, both the non-latex and latex double-glove hole puncture indication systems should be used in all operative procedures by all operating room personnel.

Equipment Design↗

Moscow Hospital School.

Among the innovations introduced during the dynamic reign of Peter the Great in his attempt to bring Russia in line with countries in Western Europe was the foundation of the Moscow Hospital School in 1707. He entrusted the direction of the school to the Dutch physician and surgeon, Nicolas Bidloo, who dedicated himself to his students and to the organisation of the school and was an excellent teacher as well as an expert in anatomy. The large number of surgical instruments listed in a catalogue drawn up when the hospital was damaged by fire in 1738 testify to the quantity and variety of surgical procedures carried out at the hospital. Equal importance was given in the courses to theory and practice, and surgery was considered on a par with medicine at a time when surgeons in most European countries were considered to be an inferior category. The high standards of the school soon won it great renown and later medical schools in Russia were modeled on this first medical institution of higher education in the country.

History, 18th Century↗

Granulation tissue removal in routine and minimally invasive procedures.

This article reviews the use of a new mechanical surgical instrument, the D'Granulator, designed to quickly and easily remove granulation tissue while maintaining a blood-free field during periodontal and endodontic surgical procedures. A technique for minimally invasive periodontal bone grafting is also given. This technique allows for minimization of soft-tissue trauma and the removal of granulation tissue from periodontal defects using a much smaller surgical incision than that used in standard bone graft techniques.

Bone Transplantation↗

Surgical approaches and techniques for managing pulmonary disease.

Common pulmonary lesions that require partial or complete lobectomy include abscesses, cysts, bullae, neoplasms, lacerations, foreign bodies, and lung lobe torsions. This article discusses the instrumentation, surgical approaches and techniques, and postoperative management of partial and complete lung lobectomy.

Animals↗

Postoperative adhesion formation after laparoscopic uterine horn resection in a porcine model: comparison of five instruments.

PURPOSE: To evaluate the postoperative adhesion formation caused by instruments used in gynecologic laparoscopic surgery and to determine the optimal instruments to use to reduce adhesions. MATERIALS AND METHODS: Seventeen juvenile pigs underwent laparoscopic bilateral resection of the uterine horns under general anesthesia and pneumoperitoneum. The laparoscopic procedures were carried out using monopolar electrocautery (ME) (n = 8), an electrothermal bipolar vessel sealer (EBVS) (n = 6), an ultrasonically activated scalpel (UAS) (n = 6), a loop-type ligature (LTL) with a steel scalpel for severing the tissues (n = 6), and an automatic stapling device (ASD) (n = 8). Second- look laparotomy was performed 14 days postoperatively, and the degree of postoperative adhesions was scored from 0 to 6. RESULTS: The mean and range of adhesion scores were 0.00 with EBVS, 0.13 (range, 0-1) with ASD, 0.33 (range, 0-2) with LTL, 1.17 (range, 0-3) with UAS, and 3.13 (range, 2-6) with ME. We found a statistically significant difference in the extent of postoperative adhesion formation associated with these 5 instruments (P < 0.001, Kruskal-Wallis test). CONCLUSION: Adhesion formation increased in the order EBVS < ASD < LTL < UAS < ME. Our study strongly suggests that surgical instruments can be selected to reduce postoperative adhesion formation, a particular concern in women of reproductive age.

Animals↗

Interactive intraoperative localization using an infrared-based system.

Conventional stereotactic surgery has evolved from a ring-based system with a simple software which calculated few parameters to frameless intraoperative localization systems that provide the surgeon with real-time localization and correlation with several imaging modalities. The localization system described in this paper is an opto-electronic system that uses infrared emitters and three precalibrated CCD cameras. The system was chosen among others for the following reasons: it tracks target points defined by up to 256 miniature light emitting diodes, and its accuracy in locating the spatial position of a diode marker in the operating volume 1.0 x 1.0 m at a distance of 2.0 m is 0.1 mm with a resolution better than 0.01 mm. Systems like this one can track and define the position and orientation of any object in the field view of the camera. This is done by attaching a few small infrared emitters (light emitting diodes) to the surface of each 'rigid body' (surgical instrument) being tracked. Subsequently, through a calibration process a corresponding rigid body file is created. This rigid body file represents this particular object (i.e. surgical tool, microscope) and defines a local coordinate system that identifies each translation and orientation of that tool with respect to the camera coordinate system. This in turn is transferred into the computed tomographic/magnetic resonance imaging coordinate system by a process referred to as coordinate matching. Fiducial markers are placed on the patient's head prior to image scanning.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiography, Digital Subtraction↗

Wound healing after photorefractive keratectomy.

For more than 15 years, the excimer laser has been used as a surgical instrument on the cornea. Photorefractive keratectomy (PRK) followed radial keratotomy as researchers sought a more precise technique. In PRK, precision turned out to depend on surgical technique as well as the wound-healing process, with the 2 factors interdependent. The PRK technique has evolved toward a large diameter, flat ablation curvatures, and an even surface. The role of such factors as cytokines and interleukins has become more clear in the past 10 years. However, understanding the wound-healing process becomes more complicated with increasing know edge. Learning the contributing factors and performing trials with new drugs and antibodies to modulate wound healing have shown positive results on the experimental level. Patient selection based on the concentration of epidermal growth factor in tears may be another way to increase PRK s precision. The PRK technique has taught much about wound healing. For the technique to be competitive, increased precision, particularly in eyes with high myopia, is needed. Two other factors are imperative: controlling postoperative pain and decreasing visual rehabilitation time.

Animals↗

The MIDCAB experience: a current look at evolving surgical and anesthetic approaches.

This article reviews and updates the recent modifications in patient selection and revisions in the anesthetic approach to MIDCAB surgery. It outlines the changing surgical selection criteria, current ways to assess graft patency, and evolving anesthetic management. A promising new advancement in coronary artery bypass, the minimally invasive technique has received varying reviews and undergoes careful evaluation. Increasing surgical experience, immediate postoperative assessment of graft patency, and improvement in surgical instruments are expected to improve patient outcome. A stratification of MIDCAB patients into status I and status II patients will aid in future evaluation of surgical and anesthetic outcome. Communication of newly developed techniques to those caring for cardiovascular patients is imperative.

Anesthesia↗

Two- and three-dimensional imaging for interventional MRI and CT guidance.

Minimally invasive techniques using endoscopes for image guided therapy are common in the surgical field and in internal medicine. Interventional procedures in the past were performed with either fluoroscopic, sonographic or CT-guidance, but now MRI-guided interventional procedures are being developed. Combining these technologies will improve surgical access and reduce complications. Today, tomographic 2 D and 3 D imaging (CT, EBT, MRI) can be used for precise and transparent guidance of endoscopes and surgical instruments inside the body for the field of minimally invasive therapy. 3 D imaging is helpful for anatomical, but not for morphological understanding. It has to be used interactively with actual cross sectional imaging for instrument guidance. This will offer a safe and effective access into the body, especially in high risk areas and lead to the new field of "Surgical Tomography".

Endoscopes↗

[An ophthalmologist's hints for organising medical help in remote areas of developing countries (author's transl)].

Judging by her experience gained in the south of Tunisia, the author suggests that instead of sending individual ophthalmologists to the developing countries it would be more advantageous to send mobile work teams in vehicles equipped with ophthalmological examination and surgical instruments and apparatus. This would be a suitable reply to the appeal made by the World Health Organization in 1973 for organising large-scale surgical treatment of cataracts with international participation within the framework of struggle against blindness in the world.

Developing Countries↗