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The extracorporeal anastomosis technique for video-assisted thoracoscopic surgery (VATS) intrathoracic esophagogastric anastomosis is a convenient, easy technique to use in VATS esophagectomy. The surgeon can assess the viability and the status of the gastric conduit, and the introduction of a circular stapler can be easily done under direct vision extracorporeally, enabling easy and simple VATS intrathoracic anastomosis between the esophagus and the gastric conduit.

Background Conservative surgery has proven advantageous in controlling hypopharyngeal squamous cell carcinoma (HSCC) and preserving speech and swallowing function in carefully selected patients, typically with early T-stages diseases. A variety of modified surgical procedures or techniques have been proposed. Methods In this study, we present a novel surgical approach for hypopharyngeal carcinoma resection utilizing the paraglottic space. Results The paraglottic space approach can help expose neoplasms under direct vision and save mucosa during surgery while sufficiently preserving laryngeal function, thus benefiting postoperative swallowing and reducing complications. A large cohort of 426 patients with HSCC underwent surgical treatment at our institution using this approach, demonstrating an overall survival (OS) rate of 52.3% and low incidences of postoperative complications. Conclusions This surgical approach can be applied in patients with the lesions that do not involve the paraglottic space.

There is a lack of guidelines concerning common carotid artery (CCA) occlusive disease in the presence of a patent internal carotid artery (ICA). A novel surgical technique that disobliterates an occluded CCA was successfully performed in three cases. The detailed surgical steps are presented herein. After proximal division of the CCA behind the sternoclavicular junction, the occluded CCA was endarterectomized via antegrade ring stripping. After removal of the atheromatous core, the CCA was everted, and the wall remnants were cleaned under direct vision. Simultaneous eversion endarterectomy of the ICA was performed when necessary. After reversion of the CCA, it was transposed and anastomosed to the ipsilateral subclavian artery distal to the orifice of the vertebral artery. This novel technique can be used in selected cases by experienced surgeons.

Impalement injuries are one of the severe types of injuries combining effects of both penetrating and blunt trauma leading to crushing injury, wound contamination, and multi-organ damage. These types of injuries are usually a result of falls from a height, vehicular accidents, and slip with strong external force. A 12-year-old boy was involved in a road traffic accident where an auto-rickshaw toppled. A loose rusted iron frame penetrated through his left knee and lower thigh. The impaled rod was removed under direct vision and the fractured lateral femoral condyle was fixed under general anesthesia. Impalement injuries require a multidisciplinary approach. The management of each case has to be individualized. Extensive wound exposure, extraction under direct vision, adequate debridement, and antibiotic coverage are pearls of management.

Augmented Reality (AR) headsets have become the most ergonomic and efficient visualization devices to support complex manual tasks performed under direct vision. Their ability to provide hands-free interaction with the augmented scene makes them perfect for manual procedures such as surgery. This study demonstrates the reliability of an AR head-mounted display (HMD), conceived for surgical guidance, in navigating in-depth high-precision manual tasks guided by a 3D ultrasound imaging system. The integration between the AR visualization system and the ultrasound imaging system provides the surgeon with real-time intra-operative information on unexposed soft tissues that are spatially registered with the surrounding anatomic structures. The efficacy of the AR guiding system was quantitatively assessed with an in vitro study simulating a biopsy intervention aimed at determining the level of accuracy achievable. In the experiments, 10 subjects were asked to perform the biopsy on four spherical lesions of decreasing sizes (10, 7, 5, and 3 mm). The experimental results showed that 80% of the subjects were able to successfully perform the biopsy on the 5 mm lesion, with a 2.5 mm system accuracy. The results confirmed that the proposed integrated system can be used for navigation during in-depth high-precision manual tasks.

Cataract surgery continues to evolve and advance in terms of new technology and improved techniques, offering a final result of better visual quality and faster visual recovery for our patients. Intraocular lens (IOL) delivery into the eye is a critical step in cataract surgery. Currently, eye surgeons load the IOL into the cartridge under the operating microscope or ophthalmic assistants load the IOL under their own direct vision. Because ophthalmic assistants load the IOL unaided, the IOL may be mishandled and lead to challenges such as IOL slippage, breakage, or incorrect orientation. In order to overcome these challenges and facilitate the surgical process, here we describe a novel technique by introducing a magnifier to the surgical table to aid ophthalmic assistants during this crucial step in cataract surgery. This not only saves time but also improves precision while loading IOL into the cartridge during cataract surgery.

We present the case of choledocholithiasis with purulent cholangitis treated with laparoscopic approach in a patient with Roux-en-Y reconstruction after total gastrectomy. After cholangiography, the common bile duct was explored with trans-cystic choledochoscopy and the retained stone extracted under direct vision.

A 65-year-old woman visited our hospital complaining of dyspnea several days before admission. A chest X-ray showed massive right-sided pleural effusion, which was not observed 1 month previously. Although the patient had never been diagnosed with cirrhosis at regular visits, the patient was diagnosed with primary biliary cholangitis at admission. Hepatic hydrothorax was suspected because pleural effusion was transudative. A diaphragmatic fistula was confirmed and closed by thoracoscopy. Pleural effusion did not reappear after this procedure. Existence of a diaphragmatic defect should be confirmed under direct vision if pleural effusion accumulates acutely or becomes beyond control.

Introduction The patients with early stage, clinically node-negative oral squamous cell carcinomas are usually treated with oral surgical excision of primary tumor. Marginal mandibulectomy of posterior mandible is difficult with an adequate safety margin via an intraoral. The cheek-splitting incision allows marginal resection at the posterior mandible under direct vision and it can avoid invasion to the neck region. The Buccal fat pad flap (BFP) grafting is considered feasible for the reconstruction of surgically induced defects, because of it has a high success rate due to BFP's rich vascularity, proximity to the recipient site, low donor-site morbidity, and simple surgical procedure for grafting. The combination of BFP and The mucosal defect covered with fibrin glue and polyglycolic acid sheet (MCFP technique) can makes early intake after surgery, excellent wound-healing and pain-relieving effects. Case report We reported a case of squamous cell carcinoma arising at the posterior mandibular gingiva that was treated by marginal mandibulectomy via a cheek-splitting transbuccal approach, reconstructed the defect after surgery using a BFP covered with MCFP technique. Conclusion A major advantage of this approach is that it obtains an adequate margin of the posterior site without requiring a cervical incision thus allowing early intake after surgery and excellent wound-healing and pain-relieving effects.

Objective. To compare the effects of continuous paravertebral block analgesia and patient-controlled intravenous analgesia after minimally invasive radical esophagectomy for esophageal cancer and their effects on postoperative recovery. Methods. A retrospective analysis was performed among 233 patients who underwent minimally invasive esophageal cancer radical operation and met the requirements, including 87 patients (group C) who were successfully placed with a continuous paravertebral block device under direct vision and 146 patients (group P) who used a patient-controlled intravenous analgesia device. Visual analogue pain score (VAS) at rest and in motion for 1, 3, 6, 12, 24, 36, and 48 hours after awakening, incidence of adverse reactions of the two analgesic methods, occurrence of pulmonary complications after operation, use of emergency analgesics, and hospital stay after operation was recorded. Results. The VAS scores of group C in resting and active state at 1, 3, 6, 12, 24, 36, and 48 hours after operation were significantly lower than those of group P (P<0.001). The incidence of adverse reactions, pulmonary complications, and the use of emergency analgesics in group C were lower than those in group P (P<0.05). The hospitalization time of group C was significantly shortened, and the satisfaction degree of group C was significantly higher than that of group P (P<0.05). Conclusion. Paravertebral block is safe and effective for patients undergoing minimally invasive radical esophagectomy. The incidence of adverse reactions and complications is lower, and the satisfaction of postoperative analgesia is higher, which is beneficial to the rapid recovery of patients after operation.

Posterior cruciate ligament (PCL) cysts are rare. Although they are usually asymptomatic and benign, in a few cases they may cause knee discomfort and restricted movements. Nonsurgical treatment is the initial approach, with medication and corticosteroid injections. However, there may be treatment failures, with some cysts needing to be excised surgically. Arthroscopic excision of PCL cysts located in the posterior compartment of the knee can be technically challenging. We describe the arthroscopic excision of a PCL cyst using a trans-septal portal, which is an easy and safe method for accessing and completely removing the lesion under direct vision.

Spear gun projectiles injuries are are very rare and are usually related to lack of attention during water- sports or fishing practices. This study aims to describe an unusual case of facial injury associated with a mandibular fracture after a spear gun shot. A 38-years-old man was admitted with a history of penetrating injury on the face caused by an accidental shot from a spear gun. After the initial stabilization and examination, the patient was taken to the surgical room for the removal of the projectile. The post-operative care was uneventful and the patient was discharged with no concerns, being in follow-up for one year with no signs of infection or malocclusion. The surgical procedure should be done as soon as possible and the removal of the spear must be done carefully, under direct vision, with or without surgical incisions. Major complications can occur after spear injuries, therefore, the patient must be observed in the postoperative period and should maintain follow up until the end of the rehabilitative process.

Introduction: Aortic valve surgery is no exception to the general rule that history is a cycle in many fields. This manuscript aims to assist readers in transitioning from past to present and on into the future within the field of aortic valve surgery. Methods: The existing literature has been examined, including old and modern articles published on pubmed, old articles non visible on pubmed, old and recent books on the history of medicine, looking for similarities and repetitions in techniques and surgical approaches to the aortic valve in the past and the current times. Results: Steps of evolution included a blind approach, plasty procedures under direct visualization of the valve without the aid of cardiopulmonary bypass, prosthetic valve replacements via sternotomies with cardiopulmonary bypass, minimally-invasive access routes, trans-catheter aortic valve implants (TAVI), suture-less prostheses, mini-thoracotomies incorporating suture-less prostheses, and finally, totally-endoscopic aortic valve replacements. Conclusion: After the advent of CPB and several decades of open-heart surgery with full sternotomies, the minimally-invasive approach has re-emerged. Supported by a commitment to smaller incisions and shorter bypass times, the concept is now being aggressively developed. The cycling of science, including the field of aortic valve surgery, means that ingenious theories and concepts that have fallen by the wayside can be brought back and explored again with current tools and enhanced knowledge.

Nasal myiasis is an opportunistic parasitic infestation of human as well as animals. Infestation of the nasal cavity by dipterous larvae is called nasal myiasis which is commonly seen in developing countries where health and sanitation are poor. Different predisposing factors associated with nasal myiasis are atrophic rhinitis, diabetes with purulent nasal discharge, midline granulomatous lesions or malignancy, and poorly nourished patients with poor hygiene. Other possible predisposing factors causing nasal myiasis include neglected children, mental retardation, and elderly age. Nasal endoscopy is a better method for removal of maggots under direct vision. Nasal endoscopic method is a better technique for the removal of maggots than conventional manual method. The maggots which are often located in deep and inaccessible areas are easily identified and removed.

Objective: The objective of this study was to evaluate augmented reality-assisted single-incision laparoscopic adrenalectomy (AR-SILA) and compare with pure SILA. Materials and Methods: Between January 2009 and March 2012, a total of 19 patients had received SILA. Eight cases were AR-SILA and the others were pure SILA. Results: Eight AR-SILA procedures and 11 SILA were successfully completed. There was no significant difference between the two groups in terms of age, body mass index, and tumor size. Operative times were shorter in the AR-SILA group (102.5 ± 12.8 vs. 150.9 ± 46.3, P = 0.005). The mean blood loss in the AR-SILA group was slightly less than that in the SILA group (60.0 ± 25.6 vs. 109.1 ± 80.1, P = 0.129). There was neither postoperative mortality nor morbidity at the time of discharge and during follow-up. Conclusion: AR-SILA provides important intraoperative information for surgeons to recognize where the pathological lesions and vessels are located beyond the surgeon's direct vision. It made SILA safer and easier.

Introduction Aortic valve surgery is no exception to the general rule that history is a cycle in many fields. This manuscript aims to assist readers in transitioning from past to present and on into the future within the field of aortic valve surgery. Methods The existing literature has been examined, including old and modern articles published on pubmed, old articles non visible on pubmed, old and recent books on the history of medicine, looking for similarities and repetitions in techniques and surgical approaches to the aortic valve in the past and the current times. Results Steps of evolution included a blind approach, plasty procedures under direct visualization of the valve without the aid of cardiopulmonary bypass, prosthetic valve replacements via sternotomies with cardiopulmonary bypass, minimally-invasive access routes, trans-catheter aortic valve implants (TAVI), suture-less prostheses, mini-thoracotomies incorporating suture-less prostheses, and finally, totally-endoscopic aortic valve replacements. Conclusion After the advent of CPB and several decades of open-heart surgery with full sternotomies, the minimally-invasive approach has re-emerged. Supported by a commitment to smaller incisions and shorter bypass times, the concept is now being aggressively developed. The cycling of science, including the field of aortic valve surgery, means that ingenious theories and concepts that have fallen by the wayside can be brought back and explored again with current tools and enhanced knowledge.

The treatment of urethral strictures remains a challenging field in urology even though there are a variety of procedures to treat it at present, as no one approach is superior over another. This paper reviewed the surgical options for the management of different sites and types of anterior urethral stricture, providing a brief discussion of the controversies regarding this issue and suggesting possible future advancements. Among the existing procedures, simple dilation and direct vision internal urethrotomy are more commonly used for short urethral strictures (

When using a gum elastic bougie, a common device to aid difficult intubations, one must appreciate the significant consequences, be prepared to manage emergency complications, and use safely by advancing under direct vision and using the markings to guide insertion.

Inferior vena cava filter (IVCF) migration to the right ventricle is a life-threatening condition. Conventionally, on-pump ventriculotomy is required if the endovascular retrieval is compromised. However, for patients in fragile physical condition, the complications of myocardial revascularization are unacceptable. We herein present a case of IVCF migration to the right ventricle in which the hook of the filter was tilted against the anterior wall of the right ventricle. The IVCF was successfully removed via a hybrid technique combining an off-pump microincision of the right ventricle with direct-vision snare capture. This hybrid technique avoided the complication of myocardial revascularization, shortened the operation time, and reduced the amount of blood loss.

Objective: To describe a surgical technique using bony septum, specifically vomer or perpendicular plate of the ethmoid (PPE), as an extended spreader graft (ESG) for securing septal extension graft (SEG) and for correcting internal nasal valve dysfunction. Methods: Design: Descriptive Case Series Setting: Tertiary Private Hospital Participants: Thirty-two (32) patients who underwent aesthetic rhinoplasty from May 2016 to October 2017 were evaluated, and ten (10) patients presenting with symptomatic obstruction were considered for inclusion. The surgical technique was applied in patients with weak SEG for control of nasal length and tip projection who had inadequate septal cartilage for SEG and ESG intraoperatively. Results were evaluated grossly under direct vision intra-operatively and post-operatively to check the patency of the internal valve. Results: Bony septum was used as an ESG in five (5) patients (1 male, 4 females, ages 35 to 50-years-old) with inadequate septal cartilage. Intraoperative evaluation under direct vision showed anterior caudal septal deviation in all 5 patients in whom correction was confirmed after placement of SEG and ESG. Immediate post-operative evaluation confirmed bilaterally patent nasal valve in all 5, who reported subjectively improved breathing at 2 and 4 weeks post-operatively. Post-operative photographs showed improvement of nasal length and tip. Conclusion: The use of the bony septum (vomer and PPE) as an ESG for primary or secondary rhinoplasty is a potentially effective means of supporting and securing the SEG for control of nasal length, preventing tip deviation or rotation and for improving internal valve function. Further trials are needed to establish its reliability and long-term effectivity. Keywords: rhinoplasty; vomer; perpendicular plate of the ethmoid (PPE)

The aim of this in vitro study was to compare the quality of digital workflows generated by different scanners (Intra-oral digital scanners (I.O.S.s)) focusing on marginal fit analysis. A customized chrome-cobalt (Cr-Co) implant abutment simulating a maxillary right first molar was fixed in hemi-maxillary stone model and scanned by eight different I.O.S.s: Omnicam&reg, (Denstply Sirona, Verona, Italy) CS3500&reg, CS3600&reg, (Carestream Dental, Atlanta, GA, USA), True Definition Scanner&reg, (3M, St. Paul, MN, USA), DWIO&reg, (Dental Wings, Montreal, Quebec, Canada), PlanScan&reg, (Planmeca Oy, Helsinki, Finland), 3D PROGRESS Plus&reg, (MHT, Verona, Italy), TRIOS 3&reg, (3Shape, Copenhagen, Denmark). Nine scans were performed by each tested I.O.S. and 72 copings were designed using a dental computer-assisted-design/computer-assisted-manufacturing (CAD/CAM) software (exocad GmbH, Darmstadt, Germany). According to CAD data, zirconium dioxide (ZrO2) copings were digitally milled (Roland DWX-50, Irvine, CA, USA). Scanning electron microscope (SEM) direct vision allowed for marginal gap measurements in eight points for each specimen. Descriptive analysis was performed using mean, standard deviation, and median, while the Kruskal&ndash, Wallis test was performed to determine whether the marginal discrepancies were significantly different between each group (significance level p &lt, 0.05). The overall mean marginal gap value and standard deviation were 53.45 &plusmn, 30.52 &mu, m. The minimum mean value (40.04 &plusmn, 18.90 &mu, m) was recorded by PlanScan&reg, then 3D PROGRESS Plus&reg, (40.20 &plusmn, 21.91 &mu, m), True Definition Scanner&reg, (40.82 &plusmn, 26.19 &mu, m), CS3500&reg, (54.82 &plusmn, 28.86 &mu, m) CS3600&reg, (59,67 &plusmn, 28.72 &mu, m), Omnicam&reg, (61.57 &plusmn, 38.59 &mu, m), DWIO&reg, (62.49 &plusmn, 31.54 &mu, m), while the maximum mean value (67.95 &plusmn, 30.41 &mu, m) was recorded by TRIOS 3&reg, The Kruskal&ndash, Wallis tests revealed a statistically significant difference (p-value &lt, 0.5) in the mean marginal gaps between copings produced by 3D PROGRESS Plus&reg, PlanScan, True Definition Scanner, and the other evaluated I.O.S.s. The use of an I.O.S. for digital impressions may be a viable alternative to analog techniques. Although in this in vitro study PlanScan&reg, 3D PROGRESS Plus&reg, and True Definition Scanner&reg, may have showed the best performances, all I.O.S.s tested could provide clinically encouraging results especially in terms of marginal accuracy, since mean marginal gap values were all within the clinically acceptable threshold of 120 &mu, m.

Augmented Reality (AR) based on head-mounted displays (HMDs) represent the most ergonomic and efficient solution for aiding complex manual tasks performed under direct vision and it is considered an enabling technology of the fourth industrial revolution (Industry 4.0). This work intends to give a harmonized and consistent overview of the workflow carried out so far in the framework of the European Project VOSTARS towards the development of a novel AR HMD specifically designed to aiding complex manual tasks within arm’s reach. First results and future developments are being presented.

The idea of isolated organ perfusion, a precursor of cardiopulmonary bypass, came by Legalois in 1812. First isolated organ perfusion was described by Loebell in 1849. The first closed system for oxygenation and returning the blood through arteries was created by Frey and Gruber in 1885. Gibbon Jr. is considered the father of extracorporeal circulation. In spring of 1934 he began constructing a machine for extracorporeal circulation in Boston. He published the first description of this system in 1937. Gibbon won the grant of the International Business Machines Corporation for developing the machine in 1947. Together they developed Model I in 1949 and Model II in 1951. After a few unsuccessful attempts in 1952, the first successful surgical intervention on the heart (closure of atrial septal defect) using cardiopulmonary bypass was performed on May 6, 1953. In 1945, Kirklin and his working group reported on a series of eight successfully treated patients in a row who underwent surgery with extracorporeal circulation. First successful valve surgery under the direct vision was performed by Dodrill in 1952, using his ?Michigan Heart? machine as a right heart bypass. Using cardiopulmonary bypass, cardiac surgeons can deal with the complex cardiac pathology and save millions of lives.

Nasogastric tube (NGT) placement in anesthetized and intubated is sometimes very challenging with more than 50% failure rate in the first attempt. We describe a newer innovative Sahu's three in one, technique with use of GlideScope and forward placement of intubated trachea by external laryngeal maneuver, these both techniques lead to separation of trachea from esophagus so that endoscopic jejunal feeding tube guide wire strengthen NGT can be guided and manipulated to esophagus under direct vision. After informed consent, we used Sahu's three in one combo technique to insert NGT in adult anesthetized and intubated patients of both the sexes with high success in the first attempt. We found this technique easy, helpful, less time consuming with high success rate.

When direct vision is obstructed, detecting an object usually involves either using mirrors or actively controlling some of the properties of light used for illumination. In our paradigm, we show that a highly scattering wall can transfer certain statistical properties of light, which, in turn, can assist in detecting objects even in non-line-of-sight conditions. We experimentally demonstrate that the transformation of spatial coherence during the reflection of light from a diffusing wall can be used to retrieve geometric information about objects hidden around a corner and assess their location. This sensing approach is completely passive, assumes no control over the source of light, and relies solely on natural broadband illumination., Non-line-of-sight sensing requires purposely controlling some of the properties of light during the measurement process. Here, the authors show that reflection from a diffusive surface preserves some coherence properties and the shape and the distance to an incoherently illuminated object can be measured using the spatial coherence function.

Introduction: Rectal cancer is a common cancer worldwide. Low rectal cancer exhibits a tendency for recurrence. Surgical resection is an important treatment for rectal cancer. Cylindrical abdominal–perineal resection is suitable for patients with low rectal cancer and has helped improve the prognosis of these patients. However, there are some difficulties during the operation. Especially the perineal area operation cannot be performed under direct vision, which affects the quality of surgical resection. To resolve these constraints, our group designed double laparoscopy assisted cylindrical abdominal–perineal resection for low rectal cancer. Conclusion: The procedure effectively solved these problems and reduced the operation time with no increase in surgery complications.

This paper presents a novel visual tracking approach that combines the NMI metric and the traditional SSD metric within a gradient-based optimization frame, which can be used for direct visual odometry and SLAM. We firstly derivate the closed form expression for first- and second-order analytical NMI derivatives under the assumption of rigid-body transformations, which then can be used by subsequent Newton-like optimization methods. Then we develop a robust tracking scheme that utilizes the robustness of NMI metric while keeping the optimization characteristics of SSD-based Lucas-Kanade (LK) tracking methods. To validate the robustness and accuracy of the proposed approach, several experiments are performed on synthetic datasets as well as real image datasets. The experimental results demonstrate that our approach can provide fast, accurate pose estimation and obtain better tracking performance over standard SSD-based methods in most cases. © 2018 SPIE.

Purpose Endoscopic placement of self-expandable metal stents (SEMSs) to relieve malignant colorectal obstruction has been widely accepted in clinical practice. Despite increasing experience, early and late complications occur with an incidence ranging from 4% to 20%. Materials and methods We have adopted a modification in the technique. A pediatric nasogastroscope (4.8 mm in diameter) has been used to pass the obstruction. It is possible to have a direct vision of the anatomy and pathology, and to pass the guidewire above the obstruction, through the nasogastroscope, under direct vision. Fluoroscopy was also used to follow the course of the guidewire and deployment of the stent. Results Early and late complications have been reduced with the new technique. Conclusions In the most recent experience of 64 patients, early and late complications have been reduced significantly. This new technique reduces radiation exposure by 70% for the patients and for the operators.

Objective To identify patient and stricture characteristics predicting failure after direct vision internal urethrotomy (DVIU) for single and short (

Background and objectives Pilonidal sinus is a common problem in the sacrococcygeal region, especially in obese, sedentary young men. The ideal surgical solution is still under debate, and there is a high rate of recurrence. In the present study, we analyzed the long-term results of a video-assisted minimally invasive technique for the treatment of sacrococcygeal pilonidal disease: endoscopic pilonidal sinus treatment (EPSiT). Methods From October 2013 through November 2015, a total of 77 consecutive patients (69 Males and 8 Females, median age: 23 y) were referred to our colorectal units. Sixty-eight patients had a primary sacrococcygeal pilonidal sinus, and 9 had recurrent pilonidal sinus; all underwent EPSiT. A fistuloscope was introduced through an external opening and the sinus cavity was completely ablated under direct vision. Postoperative complications, wound infection rate, recurrence rate, time until return to work, and patient satisfaction score were recorded during follow-up or at the last interview. Clinical data were obtained at 7, 15, and 30 days and at 6, 12, and 24 months after surgery. Results All patients completed the follow-up (median follow-up was 25 (range, 17-40) months. Median operative time was 18 (range, 12-30) minutes. The median hospital stay was 6.5 (range, 5-9) hours, and the median time to return to work was 5 days. Median healing time was 26 (range, 15-45) days. There were no major or minor complications. Six patients experienced recurrence. The overall satisfaction rate was 97%. Conclusions The ideal surgical treatment for pilonidal sinus disease should be simple and effective. In our experience, EPSiT can be performed as a day surgery, with early return to daily activities. This technique is an uneventful procedure, with good aesthetic results and a low recurrence rate.

Since the 1990s, a large body of literature has been published regarding minimally invasive coronary artery bypass grafting. Varying techniques, complexity of the procedures and the necessity of patient selection have led to its inconsistent application. We describe the standardized technique of left internal mammary artery grafting to the left anterior descending coronary artery, off-pump through a left inferior J-hemisternotomy (JOPCAB). This approach is straightforward, safe, effective, and replicable in virtually all patients. JOPCAB requires no patient selection or other prerequisite than experience in standard off-pump technique. The left internal mammary artery is harvested under direct vision through a left inferior J-hemisternotomy. The left anterior descending coronary artery is exposed with left-sided pericardial stitches. The off-pump anastomosis is performed with the aid of a suction stabilization device and routine intracoronary shunting. Patients are fully heparinized during the procedure.

Urethral stricture after radiation therapy for localized prostate cancer is a delicate problem as the decreased availability of tissue healing and the close relation to the sphincter complicates any surgical approach. We here review the pathophysiology, dosimetry, and the disease specific aspects of urethral strictures after radiotherapy. Moreover we discuss different treatment option such as direct vision internal urethrotomy as well as techniques for open reconstruction with and without tissue transfer.

Rotator cuff repairs have a high failure rate proportional to the tear size. Various techniques have been described to improve the repair strength and failure rate. The described surgical technique uses a biodegradable subacromial balloon-shaped spacer (InSpace; OrthoSpace, Caesarea, Israel) that is implanted arthroscopically to protect our tendon repair. We describe the introduction technique and suggest some hints and tricks. The spacer is placed under direct vision in the subacromial space after the rotator cuff repair is finished. Correct placement is verified by moving the arm freely. The subacromial spacer may help to protect the rotator cuff repair by centering the humeral head and reducing friction between suture knots and the acromion. It may also help to flatten dog-ear formations.

Intense interest has focused on the recent description of the anterolateral ligament of the knee. Advancing knowledge of its anatomy and function is leading to a realization of its importance in the rotatory control of the tibia in anterior cruciate ligament injuries. Reconstruction of this structure will increasingly become an important goal during anterior cruciate ligament reconstruction. However, preoperative assessment of this ligament is difficult. Clinical assessment of rotatory laxity has poor reproducibility, and it is difficult to define using current imaging techniques. This article is the first to describe a safe and reproducible arthroscopic technique to allow identification and examination of the anterolateral ligament of the knee. With the knee at 90° of flexion, the arthroscope is introduced through the anterolateral portal to allow clear visualization of the lateral gutter. Under direct vision, an accessory portal is made over the inferior limit of the lateral gutter. A shaver is then introduced through this portal and used to debride this synovial recess and define the anterolateral ligament. This allows the surgeon to examine the integrity of the anterolateral ligament, in particular its femoral insertion. If required, this additional information can facilitate the performance of a more accurate and effective extra-articular reconstruction.

Wolff and Shinya published their experience with therapeutic colonoscopy in September 1969 in JAMA [2], three months after they had commenced to perform diagnostic fiber colonoscopy. Since then, this has become an increasingly significant arm of minimally invasive colorectal surgery, complementing, even possibly replacing procedures that were once performed using “open” surgical techniques. [1-3] Following the introduction of the fiber-optic colonoscopy for diagnostic evaluation of the lower gastrointestinal tract, enabling all parts of the colon to the assessed under direct vision and instrumentation as reported by Deyhle and Demling in 1971, and Sakai in 1972, [4-5] mastery of these techniques by Williams and colleagues have enabled therapeutic interven‐ tions to be performed endoscopically. [6] Propelling this “endoscopic therapy” movement is the increasing evidence of the “adenomacarcinoma” polyp-cancer sequence introduced by Morson and Bussey from 1968 to 1970. [7] This fundamental concept has enabled a form of prevention of colorectal cancer by endoscopic removal of precursor lesions and is the basis of colonoscopic screening for colorectal cancer, resulting in the effective cessation to their progression to cancer.

Suprapubic catheter (SPC) insertion is a common urological procedure, performed both in the elective and emergency settings. The authors present an unusual case of severe intraperitoneal bleeding following the insertion of an SPC under direct vision, where the use of prostacyclin analogue may have been a contributing factor.

Background and objective Percutaneous dilational tracheostomy (PDT) is an accepted method in intensive care patients. In our neurosurgical ICU, we routinely perform PDT. We have performed 130 PDT procedures and have often observed previously reported difficulties/complications: dislocation of the endotracheal tube (ETT); frequent puncture of the ETT cuff; difficult visualization of the entire procedure because the ETT is often in the way; and risk of damaging the posterior tracheal wall due to needle puncture or rotating dilator. We believe that the rate of complications is directly related to the ability and experience of the anaesthetist carrying out the PDT. Because our hospital is a university teaching centre, PDT is often carried out by residents who are not experienced with the technique. In order to guarantee the patient's safety and to optimize the learning curve, we propose, in such circumstances, the use of a modified standard ETT. Method We developed a prototype tube for percutaneous tracheostomy procedures modifying a commercially available ETT. The idea was to create a protection shield for the tracheal wall, greater stability of the ETT in the trachea and improved vision during the whole procedure. We tested the effectiveness of the prototype on a manikin model. Conclusion The dedicated ETT eliminates puncturing of the ETT, rupture of the cuff and difficult direct vision. We report an optimal stability of the tube during the whole procedure and improvement in the efficacy and safety of the procedure. When residents attempt PDF for the first time, we believe that it would be safer and more practical to perform such a technique with the dedicated ETT.

Background: In posterior approach to the back of tibia and ankle, mere retraction of the Achilles tendon can expose the operation site but when this exposure is not enough, Z division of the Achilles tendon is recommended in literature. The main objective of the study is to find out if Z division of the Achilles tendon is always necessary in posterior approach to the back of tibia and ankle for direct vision of the back of distal tibia, exploration of bones and joints of the posterior aspect of the ankle joint. Method: From 15/12/1997 to 30/12/2006 sixteen patients required surgical management of distal tibia fractures involving articular surfaces. Posterior approach with Achilles tendon division was indicated for satisfactory access to the back of tibia and ankle. In equal number of these patients division of the Achilles tendon was either by Z or longitudinal divisions. Intra and post operative assessment of both types of Achilles tendon division was done. Results: Longitudinal division of the Achilles tendon had advantages and should be preferred. Operation time, period of post- operative pain and cast immobilization were brief. There was full range of motion of the ankle joint after removal of cast. Conclusion: When division of the Achilles tendon is indicated for direct vision of the posterior aspect of the distal of tibia and ankle joint, Z division is not necessary. A good knowledge of anatomy and experience makes the procedure easier and quicker. Keywords : Achilles Tendon, Z Division, Longitudinal Division Nigerian Journal of Medicine Vol. 17 (2) 2008: pp. 181-183

The aim of the experiment was to study the adaptive capacities of children to perform drawing movements while being visually perturbed. Children aged 5-11 years and a group of adults drew diamonds via information provided through a computer screen. The screen display was either upright or rotated 180 degrees. Results showed that the absence of direct vision of the hand yielded more perturbation in the youngest group of children compared to all other groups. In spite of some initial difficulty, all children reached accurate control after five trials. When faced with spatial rotations of the visual field, youngsters were again more perturbed than others. All children showed the same rate of adaptation to visual rotations, but they differed on adaptive strategies. Five- and 7-year-olds shifted to a feedforward mode of control consisting of the production of a rapid gesture, followed by error evaluation in order to correct their next movement. Older children were characterised by a progressive integration of reafferent visual and proprioceptive information. It resulted in an increase in duration of strokes and reduced speed, meaning enhanced on-line retrieval of information. However, 9-year-old children experienced more difficulty recuperating sensory information during movement than 11-year-olds, and kept using error feedback. Finally, visuomanual coordination in children aged 11 years, while slightly differing from that of adults, was not yet totally mature.

Background Many novel approaches to mandibular condyle fracture have been reported, but there is a relative lack of reports on the Risdon approach. In this study, the feasibility of the Risdon approach for condylar neck and subcondylar fractures of the mandible is demonstrated. Methods A review of patients with mandibular condylar neck and subcondylar fractures was performed from March 2008 to June 2012. A total of 25 patients, 19 males and 6 females, had 14 condylar neck fractures and 11 subcondylar fractures. Results All of the cases were reduced using the Risdon approach. For subcondylar fractures, reduction and fixation with plates was done under direct vision. For condylar neck fractures, reduction and fixation was done with the aid of a trochar in adults and a percutaneous threaded Kirschner wire in children. There were no malunions or nonunions revealed in follow-up care. Mild transient neuropraxia of the marginal mandibular nerve was seen in 4 patients, which was resolved within 1–2 months. Conclusions The Risdon approach is a technique for reducing the condylar neck and subcondylar fractures that is easy to perform and easy to learn. Its value in the reduction of mandibular condyle fractures should be emphasized.

The median nerve divides into its terminal branches at or proximal to the distal edge of the flexor retinaculum. An anatomy of the median nerve within the carpal tunnel is reported in two separate cases. Emphasis has been given to the value of direct vision when incising the flexor retinaculum in order to avoid injure of the median nerve.