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Accuracy and cost analysis of image-guided sinus surgery.

The use of image guidance in FESS has become widespread over the past several years. Numerous studies involving large numbers of patients illustrate the accuracy of these systems. In addition, case reports concerning patients who have extensive sinonasal neoplasms or distorted anatomy serve to demonstrate the usefulness of IGS. Studies by Metson et al [22] and Fried et al [23] have also investigated the surgeons' opinions of IGS. The vast majority of sinus surgeons have been pleased with the systems' ease of use and accuracy. Increased confidence in precisely localizing anatomical structures was the primary benefit. The major drawback to using image-guided systems was the increased operative time. Despite this, almost all surgeons who were questioned reported that they expect to increase their use of IGS in the future. By giving the surgeon real-time localization of surgical instruments, IGS could result in safer and more thorough surgery. This effect could have major implications for difficult surgeries in which distorted anatomy or extensive disease might otherwise result in incomplete eradication of the disease process. Studies examining these issues are necessary before a final conclusion can be drawn as to whether the accuracy achieved with current systems is truly beneficial and the cost is worth incurring.

Costs and Cost Analysis↗

Vascular applications of telepresence surgery: initial feasibility studies in swine.

PURPOSE: Telepresence surgery is a novel technology that will allow procedures to be performed on a patient at locations that are physically remote from the operating surgeon. This new method provides the sensory illusion that the surgeon's hands are in direct contact with the patient. We studied the feasibility of the use of telepresence surgery to perform basic operations in vascular surgery, including tissue dissection, vessel manipulation, and suturing. METHODS: A prototype telepresence surgery system with bimanual force-reflective manipulators, interchangeable surgical instruments, and stereoscopic video input was used. Arteriotomies created ex vivo in segments of bovine aortae or in vivo in femoral arteries of anesthetized swine were closed with telepresence surgery or by conventional techniques. Time required, technical quality (patency, integrity of suture line), and subjective difficulty were compared for the two methods. RESULTS: All attempted procedures were successfully completed with telepresence surgery. Arteriotomy closures were completed in 192+/-24 sec with conventional techniques and 483+/-118 sec with telepresence surgery, but the precision attained with telepresence surgery was equal to that of conventional techniques. Telepresence surgery was described as intuitive and natural by the surgeons who used the system. CONCLUSIONS: Blood-vessel manipulation and suturing with telepresence surgery are feasible. Further instrument development (to increase degrees of freedom) is required to achieve operating times comparable to conventional open surgery, but the system has great potential to extend the expertise of vascular surgeons to locations where specialty care is currently unavailable.

Animals↗

The effects of different viewing conditions on performance in simulated minimal access surgery.

This study aimed to assess performance in simulated minimal access surgery (MAS) tasks under a range of viewing conditions. MAS conventionally uses 2d viewing systems which produce a flat image. However, 3d viewing systems which produce stereoscopic depth information should in principle lead to better depth perception, and improve performance on tasks which require appropriate spatial representation of layout and depth. The study compared a novel 3d viewing system with a state of the art 2d viewing system and a direct viewing condition ('open surgery') as a point of reference. Tasks included pulling and cutting of threads using standard surgical instruments. Medical students (n = 16) were allocated to viewing conditions according to a Latin square and carried out 120 tasks each. Assessment was by means of a 3d movement tracking device providing a number of performance parameters (time on task, velocity, number of movements, distance travelled). In addition instrument movement was video-recorded and analysed by four observers to validate the tracking device. Results from tracking data and observer data were highly correlated (r > 0.85). While open surgery naturally scored highest, the key finding was the clearly superior performance in the 3d condition compared to 2d. Thus modern 3d viewing systems can improve performance in a realistic task.

Adult↗

[Patient surgical masks during regional anesthesia. Hygenic necessity or dispensable ritual?].

OBJECTIVE: The use of surgical face masks (SFM) is believed to minimize the transmission of oro- and nasopharyngeal bacteria to wounds and surgical instruments. However, there are disadvantages for patients undergoing regional anaesthesia and wearing masks: deficient assessment of lip cyanosis, anxiety, retention of CO2, costs. Up to now no studies have been published investigating whether or not SFMs, worn by patients during regional anaesthesia, will reduce bacterial convection. METHODS: We investigated 72 patients during aseptic operations: 24 individuals with regional anaesthesia and SFMs, 22 individuals with regional anaesthesia without SFMs and 26 patients undergoing general anaesthesia. Using an air sampler (volumetric impaction method) 100 L air were collected on blood agar over 2 min. After incubation at 37 degrees C over 60 h the colony forming units (CFU) were counted and differentiated. Airborne culturable bacteria were sampled over the operation field, on the anaesthetic side of the surgical curtain, as well as 10 cm before and to the side of the patients mouth. RESULTS: At all 4 locations there were no significant differences in the number of CFUs between patients wearing a SFM or not (e.g. over the operation field: patient with SFM 5.5 +/- 1.1; no SFM 4.8 +/- 1.2; mean +/- SEM). Significantly more CFUs were detected in patients undergoing general anaesthesia (p < or = 0.05). The extent of the operation did not correlate with the number of CFUs; however, we observed a trend that more CFUs were detected with an increasing number of persons working in the operating room. CONCLUSION: Surgical face masks worn by patients during regional anaesthesia, did not reduce the concentration of airborne bacteria over the operation field in our study. Thus they are dispensable. A higher airborne germ concentration has been detected in patients during general anaesthesia. The reasons for this finding are unknown, but it may be discussed as being a result of a higher activity and number of staff involved during general anaesthesia causing more air turbulence.

Adult↗

Johannes Scultetus (1595-1645). Urologic aspects in the 'Armamentarium chirurgicum'.

Johannes Schultheiss (Latinized to 'Scultetus') was one of the first academically trained physicians and surgeons in Germany in the 17th century. After his studies at the University of Padua under Adrian van Spieghel and Fabricius ab Aquapendente he became official physician of his home town of Ulm. His remarkable textbook on surgery, the 'Armamentarium chirurgicum' was first published 10 years after his death and passed through many editions and translations all over Europe. This work contains a complete catalogue of surgical instruments, illustrated demonstrations of a variety of operative procedures and 100 case reports. The success of Scultetus' publication was responsible for an improved standard of the education of the nonacademic barber surgeons, who were treating the majority of the population, and was a significant milestone for the development of surgery as an academic speciality. The life and work of Johannes Scultetus, with reference to urologic aspects, is outlined in this article.

Germany↗

An oral practical examination in emergency clinical surgery.

A body of students were asked about their views regarding an oral practical examination in clinical surgery that had been in practice for over 12 years. This is an examination with the planned objective to test problem-solving abilities and professional attitudes in emergency surgery. Verbal emergency simulation aided by appropriate pathological specimens, surgical instruments and X-rays are put forward by the examiners, and the candidate is asked to respond. One hundred and ninety-four students returned their questionnaire out of a total of 196 students (99% response rate). Candidates who were satisfied with their answers in the examination numbered 127 (65%), while 67 candidates were dissatisfied (35%). Reasons for dissatisfaction were cited as difficult and complex emergency simulation questions, expressed by 44 candidates (23%), and anxiety generated by confrontation of the examiners, expressed by 23 candidates (12%). One hundred and thirteen students (58%) thought a change in the format of the examination was not needed, while 47 students (24%) suggested a change mostly towards standardization of the examination. Emergency clinical surgery is an important area of the surgical curriculum that needs to be assessed properly. A more standardized version of this oral practical examination could perhaps provide a useful tool of assessment.

Attitude of Health Personnel↗

Laparoscopic repair of high imperforate anus.

Numerous laparoscopic operations have replaced the traditional open procedure in both adults and children. These new procedures have allowed access to body cavities without significantly traumatizing intervening tissue. The laparoscopically assisted anorectal pull-through (LAARP) for high anorectal malformations (ARM) uses fundamental concepts learned from decades of high ARM repair and incorporates modern technologic advancements in surgical instrumentation and techniques. This laparoscopic approach offers good visualization of an infant's deep pelvis with a reconstruction technique that minimizes trauma to important surrounding structures. The laparoscopic repair can be completed in one stage, 2 stages, or 3 stages. Currently, either the 2-stage or 3-stage operation is recommended. With the 3-stage approach, a temporary colostomy is created initially followed by LAARP in several weeks to months. The colostomy then is closed several months later.

Anus, Imperforate↗

[Environmental hygiene of the surgery suites for the control of surgical wound infection: Italian legislation and international guidelines].

Aim of the study is to describe the application of surgical site infection (SSI) control procedures in general surgery operating rooms of Piedmont region hospitals. A specific data collection form was designed to record information. 54 questionnaires were compiled. Piedmont legislation related to operating rooms' equipment is obeyed in more than 90% of hospitals. Nevertheless, there are some critical aspects than could be risk factors for SSI or that are not useful in order to prevent them: use of UV radiation (11.3%), use of tacky mats at the entrance of the operating room (5.7%), special cleaning of operating rooms after contaminated or dirty operations (73.6%) and routine environmental sampling (10%) that is strongly recommended by ISPESL guideline in disagreement with international recommendations. Steam autoclave is used for surgical instruments sterilization by 100% of hospitals, but only 50% of them performs an annual validation of both autoclave performance and sterilization procedures. The study gave useful information in order to promote some structural modifications and personnel education for efficacious SSI prevention and control.

Cross Infection↗

Virtual reality orthopedic surgery simulator.

This paper describes a highly interactive virtual reality orthopedic surgery simulator. The simulator allows surgeons to use various surgical instruments to operate on virtual rigid anatomic structures, such bones, prostheses and bone grafts, to simulate every procedure on the rigid structures for complex orthopedic surgeries, including arthroplasty, corrective or open osteotomy, open reduction of fractures and amputation. A comparative study of the simulator with paper simulation was performed and showed that interns and residents found the simulator to be a useful learning tool, and that visiting doctors could use it effectively for planning verification and rehearsal of operations.

Amputation, Surgical↗

Preoperative embolization of hypervascular spinal metastases using percutaneous direct injection with n-butyl cyanoacrylate: technical case report.

OBJECTIVE: Intraoperative blood loss constitutes a major cause of perioperative morbidity in surgical decompression and reconstruction of highly vascular spinal metastatic tumors. We propose a technique for embolization of highly vascular vertebral metastases using percutaneous direct injection using n-butyl cyanoacrylate (NBCA) instead of polymethylmethacrylate to complement preoperative transarterial embolization and to minimize operative blood loss. METHODS: Five patients with renal cell carcinoma metastases to the spine (one cervical, one thoracic, and three lumbar) underwent embolization by percutaneous direct injection of the affected vertebrae with a mixture of NBCA and iodized oil to supplement transarterial embolization with polyvinyl alcohol particles and fibered platinum coils. This was achieved via a transpedicular approach in four cases and by direct vertebral body puncture in one case. RESULTS: The percutaneous NBCA direct injection procedure was technically successful in all cases and was not associated with neurological or medical complications. All patients underwent subsequent vertebrectomy and spinal instrumentation. Surgical resection was performed with lower than expected blood loss and with a subjective improvement in tumor tissue handling and dissection. CONCLUSION: The extent of tumor devascularization can be improved by supplementing transarterial embolization with NBCA direct injection to decrease operative blood loss and increase the safety of surgical resection and stabilization of highly vascular spinal metastases.

Administration, Cutaneous↗

Temporary intermaxillary fixation using individualized acrylic splints permits image-data-based surgery of the lower jaw and oropharynx.

OBJECTIVES/HYPOTHESIS: Image-data-based surgical navigation is used as a helpful device in the operating room to localize critical structures with a high degree of accuracy. It also enables physicians to plan therapeutic performance. Because it relies on preoperatively acquired computed tomography (CT) or magnetic resonance imaging (MRI) data, there is restricted access for navigation of surgical instruments in areas that show motion uncorrelated with radiologic data. Thus, in the case of moveable structures, for example the lower jaw, navigational procedures could not yet be applied. STUDY DESIGN: We introduce a new technique using individualized intermaxillary splints that fix the mandible in a reproducible aboccluded position at the time of image-data acquisition and surgery. METHODS: Different manufacturing processes were investigated. The feasibility of uni- and bilateral intermaxillary splints was studied under clinical conditions in four patients during different procedures in the mandibular and oropharyngeal regions. RESULTS: The manufacturing of the splints showed was easily performed in a short time. With bilateral fixation, there was a high anatomic target precision of 1.6 to 2.3 mm. CONCLUSIONS: The use of bilateral intermaxillary splints that fix the patient's mandible in a reproducible aboccluded position permits an image-data-based navigated surgical approach to the oropharyngeal and mandibular regions.

Humans↗

Robotic and telesurgery: will they change our future?

In urology, at the end of the last millennium, there was an increasing use of computerized technology, extracorporeal shock wave lithotripsy, microwave therapy and high-energy focused ultrasound. However, experience with manipulating robots in urological surgery is still very limited. Laparoscopic surgery is handicapped by a reduction of the range of motion because of the fixed trocar position. The da Vinci system is the first surgical system to address all these problems adequately. The system consists of two main components: the surgeon's viewing and control console with three-dimensional imaging and the surgical arm unit that positions and manoeuvres detachable surgical instruments. The surgeon performs the procedure seated at the console holding specially designed instruments. Telerobotic laparoscopic radical prostatectomy provides advantages such as stereovision, dexterity and tremor filtering, but there is a learning curve with the device, mainly because of the magnification, the three-dimensional image and the lack of tactile feedback. However, after only a short period of time, the experienced surgeon is able to become familiar with the device. The impact of robotics in urological surgery is therefore very promising, and we are convinced that it will totally change the future of urological surgery.

Equipment Design↗

[The NEN (Nicolet Electronic Naviation System) ENT navigation system. Initial clinical application].

BACKGROUND: Intraoperative computer navigation will soon play an important role in procedures performed on the anterior and lateral skull base. Electromagnetic systems compared to optical systems offer some advantages such as small hardware dimension and free unimpaired mobility of the surgeon. PATIENTS AND METHODS: The NEN navigational system (Nicolet Electromagnetic Navigation System) was used in 22 patients who underwent microscopic/endoscopic surgery for polypoid rhinosinusitis. It is the prototype of a new system, which localizes the surgical probe via the measurement of pulsed electromagnetic DC fields. This system was modified for the needs of head and neck surgery. Preoperative imaging data consisted of an axially oriented spiral computed tomography (CT) resulting in a slice thickness of 1 mm with a radiation dose slightly higher than a routine coronary CT scan of the paranasal sinuses. RESULTS: The data acquired during clinical application was used to optimize navigation accuracy. The number and positions of the markers were gradually modified and improved. Six markers including the volume of the paranasal sinus system (three non-coplanar frontal markers, one on each of the mastoid processes and one median marker on parietooccipital junction) offered the best navigation precision. Additionally, all surgical instruments measured as ferromagnetic, i.e., nasal specula, were replaced by titanium instruments. An adapter affixed to the maxilla-designed to hold a second sensor used to track the patient's head was developed. With these modifications, it was possible to improve navigation accuracy to 1.5 mm in the plane of the sphenoid bone while retaining free head movement of the patient. CONCLUSION: For routine procedures such as microscopic/endoscopic endonasal sinus surgery, the systems have to be cost effective and easy to operate.

Endoscopy↗

[Application of the compression biliary-digestive anastomosis in surgical treatment of the biliary ducts obstruction].

The methods of formation and the surgical instruments for the biliodigestive compression anastomoses (BDA) doing were elaborated in the clinic. For the 1997-2000 years period 137 patients were operated on for the biliary ducts impassibility, in 36 of whom the compression BDA was formated. In 69% patients the rejection was noted on 7-10th day after the operation. The result of treatment was studied in 6 month-4 years term and estimated as good in 32 (94.12%) patients.

Adult↗

An outbreak of post-operative endophthalmitis in Lampang Hospital.

An outbreak of post-operative endophthalmitis involving 48 patients from October 1991 to October 1992 in Lampang Hospital was reported. There were 3 waves of clustered cases, i.e. from October 1991 to January 1992, April-June 1992, and August-October 1992. Investigation revealed several risk factors: defects in sterilization of surgical instruments, poor operating room hygiene, contaminated tap water and the use of multiple-dose fluids and medication. Bacteria isolated from vitreous fluid showed different bacteria, indicating multiple sources of infection or failure of asepsis. Each episode of infection was brought under control by removing the risk factors and emphasis on aseptic techniques. The value of an effective survey programme for the detection of post-operative endophthatmitis was emphasized.

Adult↗

[Development of orthopedics and founding of the Clinic for Orthopedic Surgery and Traumatology in Novi Sad].

A study of the development of the orthopaedic surgery in Novi Sad from the antique times till 1980 when the Clinic for Orthopaedic. Surgery and Traumatology was established has been carried out. Development from Roman Times till the Second World War. The first material evidence of the surgical activities in this area originates from the epoch of the Roman Empire, when under the emperor Augustus (Augustus, 27 B.C.-14 A.D.), the northern border of the Empire was established and fortified on the river Danube. At that time on the place of the contemporary Petrovaradin Fortress, a small fortification with a permanent garrison, called Cusum, was built. As it was proved by excavation of the surgical instruments from the Roman time at the nearby Sremska Mitrovica (Sirmium) the surgery in the Roman legions was quite developed and it could be concluded that some forms of surgery and orthopaedics were practised in the antique Cusum as well. There is no reliable evidence about the health service in the area after the Roman era till the 1689 when Petrovaradin was finally sized by Austrian troops from the Turks, and when the first recorded hospital (Petrovaradin Military Hospital) in this region was founded. At that time on the northern shore of the river Danube a new settlement, developing later into the town of Novi Sad, was established. Surgery together with orthopaedics at that time were performed by the so-called "feldschers", and then by primitive, self-taught surgeons who were actually experienced barbers, while educated doctors started to practice surgery only in the 19th century when the first surgical department in Novi Sad was founded in the Great Town Hospital, and for years after that, the orthopaedics was practised by general surgeons. The foundation of the Anglo-Yugoslav Children's Hospital for Tuberculosis of the Bones and Joints at Sremska Kamenica in 1934 by Dr. Katherine S. Macphail, a great benefactress of our people, was of great importance for the development of orthopaedics in this area as it was the first orthopaedic hospital in the country. The first small unit for orthopaedics, as a part of the Surgical Department of the Novi Sad State Hospital, was established in 1937 and led by a surgeon, Dr. Nikola Pravdica. Development from the Second World War till the 1980. After the Second World War the Main Provincial Hospital with two surgical departments was established in Novi Sad. At the so-called Second Surgical Department led by Dr. Nestor Teodorovic a small unit for traumatology and orthopaedics was founded in 1946, which functioned as such till 1953. The first properly trained orthopaedic surgeon was Dr. Stojan Letic who passed the specialty exam in 1953 and was attached to the Second Surgical Department of the Main Provincial Hospital. The first independent Orthopaedic and Traumatologic Department, led by an experienced orthopaedic surgeon, Dr. Vladimir Razenj, was established in 1956. From 1959 till 1963 the department was led by Prim. Dr. Dobrivoje Gradistanac. In 1963 this department together with the former "English Hospital" at Sremska Kamenica were incorporated into the so-called Clinic for Surgical Diseases and divided in the Orthopaedic (led by Prof. Milenko Dosen) and separated Traumatologic (led by Prim. Stojan Letić) departments which existed as such till 1975 when they were integrated again into a single unit which evolved into the Clinic for Orthopaedic Surgery and Traumatology in 1980.

Health Facilities↗

[Identification and removal of orbital foreign bodies using the CAS (Computer-Assisted-Surgery) system].

Identification and extraction of orbital foreign bodies can cause problems in special cases. Small, retroocular localized fragments can be hard to detect, severe bleeding and traumatically damaged anatomy can render orientation difficult. At the Department of Otolaryngology, Plastic Head and Neck Surgery of Aachen University Hospital we used the investigational new CAS (Computer-Assisted-Surgery) device in several such cases with good success. CAS is a new localizing technique designed to assist the head and neck surgeon during surgery providing real-time position information. The method is based upon a three dimensional volume model of the patient's skull generated by preceding computed tomography imaging procedures such as CT or MRI scan. Intraoperative correlation of 3D-model and the patient's skull allows for real-time position display of a surgical instrument on the monitor screen. Accuracy of the method has been experimentally determined to be within 1 mm. Thereby the surgeon is able to localize even small foreign bodies without extensive exploration. In the case of multiple foreign bodies the surgeon gets a simple documentation facility, which of the visible fragments have already been extracted. Medially placed foreign bodies could be removed via an endonasal approach. Encouraged by these results we recommend CAS for the extraction of orbital foreign bodies.

Accidents, Occupational↗

Application of a rapid-prototyped temporal bone model for surgical planning.

CONCLUSION: This 3D prototyped model constructed using a selective laser sintering method serves as a good material for surgical simulation of a malformed ear. OBJECTIVE: In order to perform surgery of the malformed ear, a thorough understanding of the anatomy of the ear is required, together with sufficient experience. The aim of this study was to investigate the validity of a prototyped temporal bone model for surgical simulation. MATERIAL AND METHODS: Simulated 3D models of two cases of congenital aural atresia were prototyped using a selective laser sintering method. Conventional surgical instruments were used to dissect the models. RESULTS: Abnormal structures of the middle ear, such as the ossicles, labyrinth and facial nerve, were identified by dissecting the model. Presurgical dissection informed the surgeon of the optimum orientation for surgery. The model was disinfected and could be handled by the surgeon in the operating room. Surgery could be carried out safely although in one case it was canceled because of the highly abnormal location of the middle ear cleft and facial nerve.

Adult↗