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Superior technique necessitates effective intraoperative communication. Hand signals can convey most of the wishes of the surgeon. Pragmatic execution calls for mixing hand signals with anticipation and verbal commands.
INTRODUCTION: During a surgical procedure, an attending may propose a surgical treatment that a resident believes is not the standard of care based on previous readings, discussions with other faculty, or experience. We hypothesized that resident disagreements over intraoperative management are common and are handled differently by residents than faculty members perceive. METHODS: Surveys were sent to 68 residents (82% response) and 45 faculty (91% response) in general surgery and seven subspecialties. Questions were asked to determine the frequency of disagreements and the differences in perceptions of how residents should act when they have disagreements over the intraoperative decisions of attendings. Significance was defined using Fisher's exact test at P < 0.05. RESULTS: Residents reported having major disagreements with faculty over intraoperative decisions as often as monthly (41%) or two to three times per year (37%). Estimates of the frequency of major resident disagreements did not differ between attendings and residents. Fewer residents felt comfortable asking the faculty to discuss their intraoperative decisions than was perceived by faculty members (41% vs 78%, P < 0.001). Residents at all levels are less comfortable than perceived by their mentors in discussing intraoperative decisions even when residents believe that patient injury may result. Residents felt that most of their disagreements occurred because of attending knowledge deficit, while most attendings attributed these differences to resident knowledge deficits. CONCLUSION: Residents frequently have disagreements with faculty over intraoperative management. Education to improve preoperative and intraoperative communication between surgical residents and faculty is needed.
The wait while a family member or loved one is undergoing surgery is stressful and anxiety-producing. Perioperative nursing contact during this period can result in positive outcomes of decreased anxiety, increased receptivity to postoperative information, and increased awareness of the professional practice. Perioperative nurses have the skills and the opportunity to provide progress reports to the client's family, at least once during surgery. Characteristics important to this role include motivation and commitment to be informative; caring; sensitivity and perceptivity; sense of humour; and education. Possible barriers to intraoperative communications include various lacks--of time; attention (related to monitoring requirements in the operating room); support from management, peers, and doctors; and therapeutic communication skills to alleviate anxiety. Progress reports to the family can decrease their physical stress and add to their satisfaction with the hospital.
We evaluated the intraoperative utility of monitoring median nerve somatosensory evoked potentials (SEPs) in 31 consecutively hospitalized neurosurgical patients (mean age 55.3 +/- 2.1 years) who underwent spinal cord decompression for cervical herniated disc, spondylosis, or tumor. Pre- and postoperative standard neurological examinations included evaluation of motor function, sensory responses, gait, tone, and reflexes. Evoked potentials were recorded from clavicular Erb's (N9) and contralateral cortical (N20) points. Intraoperatively, SEP measurements were obtained after the onset of anesthesia (baseline control) and were repeated throughout the operative procedures. N20 and N9-N20 conduction latencies were measured for each SEP recording; disappearance of the SEP waveform was interpreted as a nonquantifiable increase in latency. Follow-up neurological examinations were made immediately after and up to 6 months following surgery. Postoperatively, the 31 study subjects were assigned to one of two groups based on neurological evaluation: 27 group I subjects had either no change or improvement (good outcome) whereas four group II subjects had postoperative neurological deterioration (poor outcome). Intraoperative N9-N20 interpeak latency was found to increase during cervical decompression in six of 27 group I and in two of four group II subjects. Only two of the Group I subjects exhibited increases > 10% (14 and 19%, respectively). Intraoperative communication to the surgeon of a marked increase of N9-N20 latency during positioning for cervical traction clearly obviated a poor outcome in one group I subject; Upon removal of traction, latency decreased and significant changes in neurological function were not detected postoperatively. The SEP waveform disappeared in two of the group II and in none of the group I subjects. In the two group II subjects exhibiting increases of N9-N20 latencies, increments were > 20%. These findings indicate that in patients undergoing cervical spinal cord decompression, disappearance of SEPs or increases > 20% in the N9-N20 interpeak latency are suggestive of operative conditions that place patients at risk for poor neurological outcome.
The authors conducted an open-label nonrandomized parallel trial to examine whether the preoperative application of povidone-iodine to the ocular surface reduces the incidence of endophthalmitis after intraocular surgery. During an 11-month period, topical 5% povidone-iodine was used to prepare the conjunctiva in 1 set of 5 operating rooms, while silver protein solution was used in another set of 5 rooms. In all cases, surgeons continued to use their customary prophylactic antibiotics. A significantly lower incidence of culture-positive endophthalmitis (P less than 0.03) was observed in the operating rooms using povidone-iodine (2 of 3489 or 0.06%) compared with those using silver protein solution (11 of 4594 or 0.24%). Use of topical povidone-iodine in over 3000 cases was not associated with any adverse reactions. In a majority of the observed cases of endophthalmitis, some form of intraoperative communication with the vitreous cavity existed.
The authors conducted a case-control study to identify risk factors for postoperative endophthalmitis. Fifty-four cases of patients who developed endophthalmitis after intraocular surgery at the New York Eye and Ear Infirmary during the period from January 1988 through October 1990 were identified. A control group of 228 patients was randomly selected from the 24,105 patients who underwent intraocular surgery during this same period. Logistic regression analysis identified significant independent risks associated with intraoperative communication with the vitreous cavity (risk ratio 13.7, P less than 0.001) and use of an intraocular lens with haptics made of polypropylene (risk ratio 4.5, P = 0.007). The study predicts that there would be approximately 700 fewer cases of postoperative endophthalmitis annually in the United States (approximately a 50% decrease in incidence) if intraocular lenses with haptics made of polymethyl-methacrylate, rather than polypropylene, were used exclusively.
In maxillofacial surgery the quality of the surgical outcome mainly depends on the experience of the operating surgeon. Thus we intend to support the surgeon before and during surgery in order to enhance the surgical results. On the one hand this implies the use of image processing, three dimensional modelling techniques and visualization techniques of medical image data, on the other hand planning systems, intraoperative navigation devices and surgical robots are needed. In this paper a complex expert system is presented, which uses a planner for generating treatment plans, an infrared navigation for monitoring both patient, robot, and surgical tool, and a surgical robotic system in order to work on bone. Special stress is laid on the architecture of the planning system, the structure of the treatment plans, and the intraoperative communication protocols.
The authors have devised an "arthroscopy language" to make orthopaedic surgeons' intraoperative communication clear, comprehensive, and concise. This language specifically eliminates surgeons' "freestyle" conversation at the most crucial moments of their procedure, when concentration and the coordinated work of two surgeons are essential. The language uses current arthroscopic terminology and new words that have been adapted by the authors to describe all the basic maneuvers that are used during any arthroscopic procedure. The authors believe the language brings the necessary scientific sophistication into arthroscopic surgeons' speech in the operating theater.
The intraoperative anatomical findings of the anterior communicating artery (ACoA) complex in 46 patients with anatomical variations were compared to those in an equal number of patients without variations in order to determine the visualization of the elements of the vascular complex. All patients underwent radical surgery for an ACoA aneurysm by one of three different surgical approaches: transsylvian, anterior interhemispheric, or basal interhemispheric. Visualization of the vascular elements was similar in patients with or without anatomical variations. The differences observed were dependent on the surgical approach selected and on the projection of the aneurysm. It was found that, even when the intraoperative anatomical field and the number of vascular elements visualized are different from those obtained in autopsy studies, the vascular microanatomical characteristics can be confirmed with each surgical approach to the extent necessary to ensure safe clipping of aneurysms in patients both with and without anatomical variations.
This microsurgical study attempts to analyze the intraoperative anatomic vascular variations associated with the anterior communicating artery (ACoA) aneurysms in 120 patients who were operated on at the Neurosurgical Department of Atatürk University Medical School, Erzurum, Türkiye. All patients underwent radical surgery for aneurysm by the right pterional approach. The findings were recorded during surgical intervention and through the slides and videotapes of the operations. A total of 72 (60%) of our patients had vascular variations in the vicinity of the ACoA. Marked hypoplasia of the A1 segment of anterior cerebral artery (ACA) at the right or left side (26.6%, n = 32), median artery of the corpus callosum (MACC) (14%, n = 17), duplication of the ACoA (8.3%, n = 10), duplication of the A1 segment of ACA (7.5%, n = 9) and azygous pericallosal artery (3.3%, n = 4) were the variations that were observed during operations. A retrospective study of the cerebral angiograms of the cases indicated that preoperative diagnosis of the A1 or ACoA duplication was not possible, 14 (82.4%) of the 17 MACC's were easily identified, while three (17.6%) could not be diagnosed. From this intraoperative study, we concluded that, regardless of whether a vascular variation has been identified preoperatively, ACoA aneurysm surgery should be undertaken with the possibility of an MACC in mind. The recognition of the anatomic variations of the ACoA and the detailed knowledge of the microvascular relationships of the aneurysms will allow the neurosurgeons to construct a better and safer microdissection plan to save time on the one hand and to prevent postoperative neurological deficits on the other.
Branchio-oto-dysplasia is characterized by abnormalities of embryonic branchial arch system and deafness inherited as autosomal dominant with variable gene expression. We present a rare case of multiple intracranial aneurysms associated with branchio-oto-dysplasia. A 40-yr-old man with severe headache presented as spontaneous subarachnoid hemorrhage on brain computed tomographic scan. The patient also manifested clinical features of branchio-oto-dysplasia and right hemifacial hypoplasia. Carotid angiogram confirmed an aneurysm in the anterior communicating artery. Intraoperative findings demonstrated multiple aneurysms in the anterior communicating artery and in the left posterior communicating artery, which were clipped successfully. Postoperative course was uneventful. This condition has not been reported previously. We also reviewed literatures to discuss whether the intracranial aneurysm was as a coincidental finding or a part of this malformation.
BACKGROUND: Women with communicating double uterine anomalies are at increased risk for obstetric complications, including early pregnancy loss, preterm delivery, and breech presentation. We present the pregnancy of a woman with a previously diagnosed communicating double uterine anomaly. CASE: An 18-yr-old white female with a previous diagnosis at age 11 of a communicating double uterus, double cervix, and obstructed left hemivagina was followed during the course of her pregnancy. She experienced no complications until 36 6/7 weeks, when she was found to have signs and symptoms of mild preeclampsia. The fetus was in a breech presentation and a cesarean section was performed. Two hemiuteri were identified intraoperatively. The communication was not visualized. A viable male infant was delivered without complications. CONCLUSION: This patient represents only the sixth report of successful pregnancy in a woman with a Toaff type 5A communicating uterine anomaly.
BACKGROUND: Micro-anatomical parameters of the hypoplastic posterior communicating artery (PCoA) are assessed and compared with the micro-anatomical parameters of the adult type PCoA. Based on the results obtained, the safest place is proposed for PCoA division during basilar tip aneurysm surgery via the pterional route. METHODS: In 35 human cadaver brains, red coloured latex was injected and micro-anatomical dissection was performed. RESULTS: Seventy PCoA were found. Adult type PCoA was found in 29 cases (41.43%) with mean length 12.58 mm. Reduction of the PCoA diameter from its anterior to its posterior third by up to 20% was found in 27% and by more than 20% in 10% of the cases. The mean perforating vessel number was 8.17, distributed in each third: 3.48, 2.90 and 1.79, respectively. A hypoplastic PCoA was found in 33 cases (47.14%) with mean length 16.09 mm. The PCoA's diameter reduction by up to 20% was found in 24% and by more in 27% of the cases. In 6% of the cases an extreme reduction by up to 70% was observed. The mean perforating vessel (PV) number was 8.82, distributed in each third: 3.18, 3.36 and 2.27, respectively. CONCLUSIONS: Hypoplastic PCoA tends to be longer and with a more distinct diameter reduction from the anterior to the posterior third than the adult type PCoA. The PV anatomical parameters are similar for both groups. The posterior third of the PCoA seems to be the area where the risk of perforating vessel damage is the least when performing intra-operative PCoA division.
BACKGROUND: The relationship between surgical volume and clinical outcome is well established in adult pancreatic surgery. We examined whether this relationship is applicable in pediatric surgery, given that very few cases are done regularly by pediatric surgeons even at tertiary centers. METHODS: A retrospective analysis of all patients who underwent pancreaticoduodenectomies between 1993 and 2003 was done. Comparisons were made to the largest recent series of pancreaticoduodenectomies in the adult literature. RESULTS: With the age at presentation from 9 to 17 years, 5 patients were identified. Mean operative time was 451 minutes with a median of 363 minutes compared with the mean and median in the adult literature of 420 minutes. Clean margins were obtained in all patients compared with 71% in adults. Mean follow-up was 35 months. All patients are alive, with 1 patient who has underwent subsequent resections for local recurrence. CONCLUSION: Although 5 consecutive cases of pancreaticoduodenectomies represent very low volume compared with high-volume adult centers, minimal difference in operative time, length of stay, and mortality (none) were observed in this series. Therefore, unlike adults, particular case volume in the pediatric population may not be a significant factor because of the nature of pancreatic pathology, patient characteristics, and hospital and surgical environment.
INTRODUCTION: This paper describes a method of assessment of invasive clinical procedures which are currently being devised, and which are perceived to be a method that may be used to complement OSCEs in overall clinical skills assessment. OBJECTIVE: The objective of the Structured Clinical Operative Tests (SCOT) is to introduce a greater level of objectivity to the assessment of operative clinical skills. Invasive or irreversible clinical operative procedures from a large part of dental undergraduate training and are by their very nature precluded from OSCE scenarios. It is also important to test intraoperative skills, communication skills and contingency management, and performance of these with awareness of the psychosocial context and ethical framework. The paper describes the use of checklists in the monitoring of clinical operative skills in a more authentic clinical situation using the SCOT. FORMATIVE ASSESSMENT: Continuous assessment should a) record achievement of competency in as objective a manner as possible and b) should encourage continuous self-evaluation. In the SCOT the students reflect on their clinical performance and in consultation with their supervisors record their plans to improve their competence in that skill or procedure in the future. This is done immediately on completion of a clinical task while the experience is still fresh in the mind. This encourages deep reflective learning as opposed to superficial factual learning which is characteristic of the more traditional curriculum, and is described as supervisor validated self-assessment. DISCUSSION: The discussion outlines how SCOTs can be practically implemented and integrated into the undergraduate curriculum and an example of a SCOT is appended to the paper. The scope for using SCOTs in postgraduate assessment such as in VT/GPT is also described.
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A B-scan real-time ultrasonic equipment providing three-dimensional information was used for intraoperative localization of renal calculi. Simplicity, non-invasiveness and ability to demonstrate radiolucent calculi or matrix are stress as the main advantages of the method. Its current use on a larger scale is expected and regarded as desirable.
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