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Objective The aim of this study was to explore the clinical effect of treatment for recurrent axillary osmidrosis (AO) after small-incision minimally invasive surgery by trimming and electrocoagulation of apocrine glands under direct vision through double incisions parallel to axillary creases. Methods This was a retrospective study. From September 2012 to January 2019, 75 axillae in 48 cases of recurrent AO after small-incision minimally invasive surgery were treated using trimming and electrocoagulation of apocrine glands under direct vision through double incisions parallel to axillary creases. Patient data, such as sex, age, original surgery method, the severity of underarm malodor before and after the operation, and occurrence of complications, were collected and analyzed. Results For the follow-up of at least 12 months after the surgery, all patients' underarm malodor disappeared or was significantly reduced. Patients with preoperative severity of grade I did not show a recurring AO, whereas the recurrence rate of grade II and grade III AO was 7.9% and 14.3%, respectively. Furthermore, the AO recurrence rate was 9.1% for those younger than 18 years and 6.2% in those 18 years or older. Subcutaneous hematomas appeared on 3 axillae (4.0%), and the contraction of subdermal fibrotic bands appeared on 5 axillae (6.7%). Conclusions Patients with recurring AO after small-incision minimally invasive surgery achieved good treatment results by trimming and electrocoagulation of apocrine glands under direct vision through double incisions parallel to axillary creases.

Purpose of review To explore and report the recent evolution of transurethral management of urethral stricture disease. Recent findings In recent years, new promising techniques in the transurethral management of urethral stricture disease have emerged including adjuvant therapies to direct vision internal urethrotomy, regenerative therapy with buccal mucosa cells and minimally invasive transurethral urethroplasty procedures that avoid skin incisions. Summary Although further work is needed, the expanding field of transurethral therapies for urethral stricture disease demonstrates early promising results through a variety of modalities.

Introduction Mandibular distraction osteogenesis (MDO) effectively treats upper airway obstruction (UAO) in young patients with Robin sequence (RS). The most commonly used MDO devices have internal and external components that require manual activation. Although complications associated with MDO in infants with RS have been well documented, hardware/device malfunction has not been precisely described. The present study reports the authors' recent experiences with such problems, in an effort to shed light on these complications and identify potential steps to mitigate future related issues. Design The authors reviewed a prospectively gathered database to identify all young children under the age of 3 years who underwent MDO using buried internal devices for UAO associated with grade 3 RS from March 2007 to September 2019. We specifically focused on complications attributable to the hardware itself. Results Nineteen patients with 40 devices met inclusion criteria. The median age at MDO was 2.3 months (interquartile range 1.4-6.3 months). Intraoperative activation of all devices under direct vision resulted in satisfactory distraction. Four devices (10.5%) developed postoperative complications directly related to the device, including break down of component parts (N = 3) and failure to maintain distraction distance (N = 1). Two patients required surgical replacement of one device each, whereas the remaining complications occurred during the consolidation phase and did not require intervention. Conclusions This report documents a series of device/hardware malfunction in infants and young children undergoing MDO for severe UAO associated with RS. Despite rigorous testing and development, these devices may fail, resulting in patient morbidity.

Objectives Fishbone ingestion is a common problem worldwide, and the first step for managing this condition is to locate the fishbone precisely. However, until now, no study has analysed the true location of fishbone and its associated factors. Thus, this study identified the factors predicting the true location of fishbone and subsequently attempted to provide a management algorithm for fishbone ingestion. Patients and methods This retrospective study was carried out at St Martin De Porres Hospital, Taiwan, between January 2015 and January 2016. All patients were diagnosed as having fishbone ingestion within the pharynx and underwent fishbone removal. Results This study included 198 consecutive patients with a mean age of 43.1 years (range: 1-84 years). The sensitivity of lateral neck radiography in the diagnosis of fishbone in the pharynx was only 22%. The fishbone locations were as follows: the tonsil in 72 (36.4%) patients, the tongue base / vallecula in 112 (56.6%) and the hypopharynx in 14 (7.0%). Multiple logistic regression analysis showed that patient age and fishbone length were significant independent risk factors associated with the true location of fishbone ingestion. Among all patients, fishbone was removed transorally under direct vision in 73 (36.9%) patients and using flexible nasopharyngoscopy in 125 (63.1%) patients. Conclusion Patient age and fishbone length are important independent factors associated with the location of ingested fishbone. Lateral neck radiography is not beneficial for diagnosing fishbone ingestion within the pharynx. Flexible nasopharyngoscopy, by contrast, is an important method for the diagnosis and treatment of fishbone ingestion within this location.

OBJECTIVE To evaluate the accuracy of gynecologic surgeons at estimating uterine dimensions and weight. METHODS Six model uteri of various sizes were created to simulate the size and consistency of a uterus and displayed at 3 stations. The visual station (VS) comprised 2 specimens placed on an unmarked table. The laparoscopic station (LS) consisted of 2 model uteri, each placed in a separate simulated abdomen with a 0 degree laparoscope and 2 operative trocars with standard instruments. The blind weight station (BWS) consisted of blind palpation of 2 separately weighted models (heavy model [HM] and light model [LM]). Participants visually estimated the dimensions of each VS and LS models and blindly palpated the BWS models to estimate weight. RESULTS Participants included 15 residents, 27 attendings, and 6 medical students. There was no difference in estimation accuracy regarding gender and age. For the VS and LS groups, participants underestimated all dimensions (VS variance = -15.0%; P < 0.001 and LS variance = -31.9%; P < 0.0001). Laparoscopic estimation was less accurate than direct vision (P < 0.0001). Attendings and residents equally underestimated the 3 dimensions visually (P = 0.46), but attendings were more accurate at estimating laparoscopic dimensions (-25.8% vs -41.1%; P = 0.0001). All groups overestimated model weights (HM variance, 92.5%; P < 0.001 and LM variance, 132.0%; P < 0.0001), with attendings more accurate than residents (39.7% vs 167.6%; P = 0.015 for HM and 52.0% vs 238.5%; P = 0.035 for LM). CONCLUSIONS Gynecologic surgeons at all levels of training are inaccurate at estimating dimensions and weights. With surgical decisions often predicated on estimates, education is needed to improve estimation methods.

INTRODUCTION AND OBJECTIVES:Introduction & Objective: Urethral strictures are most commonly treated via minimally invasive techniques such as dilation or direct vision internal urethrotomy (DVIU); ...

Titanium plate systems are used frequently for bone fractures and postosteotomy fixation in craniomaxillofacial surgery. However, sometimes the head of the screw for plate fixation is deformed or the screw breaks in the bone. Screw removal can be difficult in these cases. In this study, we examined the utility of the Screw Extraction Set (Synthes Inc) in facilitating the removal of screws broken in craniomaxillofacial bones. In the past, we often encountered screw head sockets that had become deformed. In the removal of such a screw, the extraction screw tip did not engage well with the deformed screw head socket because the extraction screw tip was angled obtusely. Thus, its removal was difficult, and this method was clearly problematic. Using the Screw Extraction Set, the removal method for a screw broken in the bone was relatively easy. In particular, it was very convenient in removing broken screws in the mandibular angle and ramus, where surgery is difficult under direct vision. This system was thought to be useful for craniofacial surgeons if proper patient selection is performed.

Introduction: Impalement injury is an uncommon presentation, and penetrating chest injuries account for 1% to 13% of thoracic trauma hospital admissions. The vast majority of patients with penetrating thoracic trauma who survive to reach the hospital alive can be managed nonoperatively. Nevertheless, in 10% to 15% of cases, emergency operation is necessary due to the associated hemorrhagic shock and visceral injury. Case presentation: Here, we report on a 39-year-old male, a construction worker, who fell down from a height of a construction site, landing ventrally on a clump of iron rods with 4 projecting heavy metallic rods penetrating into his thorax and head (scalp pierced only). Emergency surgery was taken, and the patient had an uneventful successful outcome. Conclusions: After massive thoracic impalement, rapid transportation to a tertiary trauma center with the impaled objects in situ can improve the outcome. Video-assisted thoracic surgery (VATS) is recommended to remove the foreign body under direct vision and to reduce the incidence of missed, potentially fatal vascular or visceral injuries.

Open release of the transverse carpal ligament (TCL) has been the gold standard surgical treatment for patients with carpal tunnel syndrome over the past 50 years. Transecting the TCL with a scalpel under direct vision produces reliable symptom relief in the vast majority of cases. However, despite the clinical success of this technique, transient post-operative “pillar pain,” scar tenderness, or weakness are known to occur in some patients.

Background and objectiveTracheal intubation may be more difficult in morbidly obese patients (body mass index >35 kg m−2) than in the non-obese. Recently, new video-assisted intubation devices have been developed. After some experience with videolaryngoscopy, we hypothesized that it could improve the laryngoscopic view in this specific population and therefore facilitate intubation. The aim of this study was to assess the benefit of a videolaryngoscope on the grade of laryngoscopy in morbid obesity.MethodsWe studied 80 morbidly obese patients undergoing bariatric surgery. They were randomly assigned to one of two groups. One group was intubated with the help of the videolaryngoscope and in the control group the screen of the videolaryngoscope was hidden to the intubating anaesthesiologist. The primary end-point of the study was to assess in both groups the Cormack and Lehane direct and indirect grades of laryngoscopy. The duration of intubation, the number of attempts needed as well as the minimal SPO2 reached during the intubation process were measured.ResultsGrade of laryngoscopy was significantly lower with the videolaryngoscope compared with the direct vision (P < 0.001). When the grade of laryngoscopy was higher than one with the direct laryngoscopy (n = 30), it was lower in 28 cases with the videolaryngoscope and remained the same only in two cases (P < 0.001). The minimal SPO2 reached during the intubation was higher with the videolaryngoscope but it did not reach statistical significance.ConclusionsIn morbidly obese patients, the use of the videolaryngoscope significantly improves the visualization of the larynx and thereby facilitates intubation.

The infracture technique for reduction malarplasty has been widely used as an aesthetic surgical procedure in northeast Asia. Since 1988, the authors' original method of infracture technique was performed through the combined approach of intraoral and temporopreauricular incision, which may leave a rather long scar on the temporal region. To shorten the external scar, a new technique using a short preauricular incision instead of a long temporopreauricular incision was developed. From September of 2000 to June of 2001, this new approach was applied to 142 patients for correction of prominent zygoma. In this procedure, anteriorly, incomplete fracture of the zygomatic body was performed through an intraoral approach for bending inward. Posteriorly, full-thickness cutting of the zygomatic arch was performed through a preauricular incision. Then, lateral bulging of the zygomatic arch was reduced with infracturing, and the infractured site was fixed in a new position with a microplate and three screws. The advantages of this technique are reduction of the operation time, reduction of the length of the external scar, and reduction of postoperative edema around the operative region. With this combined approach, the authors were able to sufficiently expose the zygomatic arch and body and able to change the lateral convex arch into a concave one. Under direct vision, the authors could effectively and precisely perform the infracture technique through a much shorter preauricular incision that did not result in a long, conspicuous external scar.

Background Pain control following abdominoplasty is a major source of concern for the patient and surgeon alike. Pain pumps and opiate medications are currently the frontline therapies. With the following technique, Exparel (liposomal bupivacaine, 72-hour duration of action) has been used for transversus abdominis plane (TAP) blocks under direct visualization during abdominoplasty with the goal of improving pain control during the early and intermediate recovery period. Materials and methods In this pilot study, 13 consecutive patients were treated with the direct, fascial-splitting technique to reach the TAP plane. Using a spinal needle, 20 mL of liposomal bupivacaine was injected deep to the internal oblique fascia bilaterally under direct vision. Primary and secondary endpoints of total opiate use and patient reported pain scores were assessed. Results All 13 patients met inclusion criteria as abdominoplasty patients with adequate follow-up data. The average visual analog scale pain score was 2.5 on postoperative day 1 and 1.7 on postoperative day 3. The average total opiate use (the number of 10 mg oxycodone tabs consumed) was 7.5 or 75 mg per patient. Conclusions This pilot study demonstrates the safety and efficacy of liposomal bupivacaine TAP blocks under direct vision. Favorable pain control was demonstrated. This represents an exciting opportunity to decrease postoperative pain in the early and intermediate recovery period after abdominoplasty.

Purpose We present an approach to laparoscopic radical nephrectomy and intact specimen extraction, which incorporates hand assisted and standard laparoscopic techniques. Materials and Methods A refined approach to laparoscopic radical nephrectomy is described and our experience is reviewed. A low, muscle splitting Gibson incision is made just lateral to the rectus muscle and the hand port is inserted. A trocar is placed through the hand port and pneumoperitoneum is established. With the laparoscope in the hand port trocar 2 additional trocars are placed under direct vision. The laparoscope is then repositioned through the middle trocar and standard laparoscopic instruments are used through the other 2 trocars including the one in the hand port. If at any time during the procedure the surgeon believes the hand would be useful or needed, the trocar is removed from the hand port and the hand is inserted. Results This approach has been applied to 7 patients. Mean estimated blood loss was 200 cc (range 50 to 300) and mean operative time was 276.7 minutes (range 247 to 360). Mean specimen weight was 767 gm. (range 538 to 1,170). Pathologically 6 specimens were renal cell carcinoma (grades 2 to 4) and 1 was oncocytoma. Mean length of hospital stay was 3.71 days (range 2 to 7). There were no major complications. Conclusions We believe that this approach enables the surgeon to incorporate the advantages of the hand assisted and standard laparoscopic approaches.

Recently the technique of percutaneous nephrostomy has been modified to allow the percutaneous extraction of urinary calculi. This communication describes experience with the percutaneous extraction of 63 calculi from the urinary tract. An overall success rate of 87%, a low incidence of complications (about 3%), a fast recovery, and sooner return to work are obtained. Several technical variants includings grasping, fragmentation, flushing and removal under direct vission have been used. In most cases, a combination of the different techniques has to be used in one patient. Essential to the technique is the introduction of large dilators into the kidney.

INTRODUCTION AND OBJECTIVES: Direct vision internal urethrotomy (DVIU) is the first option for the treatment of short anterior urethral strictures. However, long-term outcome is not favorable. Our purpose is to determine patients at risk of recurrence in a large contemporary series. METHODS: We retrospectively analyzed the data sheets for adult patients (>18 years) underwent DVIU for urethral strictures between January 2002 and January 2013. Patients’ demographics and stricture characteristics by retrograde urethrography and operative findings were analyzed. The primary outcome is the development of failure defined as the need for any further intervention e.g. endoscopic or substitution after catheter removal. Univariable and multivariable analyses were used to identify patients at risk of failure. RESULTS: A total of 563 patients with a mean SD age of 49.9 15.9 years were analyzed during the specified period. The main cause of stricture was idiopathic in 51.9% and the strictures were multiple in 17 (12.4%) patients with median diameter and length of 2 mm and 6 mm, respectively. Recurrence developed in 128 (22.7%) patients over a median followup of 36 months (3-280). Patients developed recurrent strictures were obese (p 1⁄4 0.012). Post-traumatic and idiopathic strictures had higher incidence of recurrence than iatrogenic and inflammatory strictures (p 1⁄4 0.001) while distal strictures had significantly more tendency to recur than proximal strictures (p 1⁄4 0.01). None of the stricture characteristics by retrograde urethrography was significantly associated with recurrence. On binary logistic regression analysis, obese patients (OR: 1.7; p 1⁄4 0.013), distal strictures (OR: 2; p 1⁄4 0.011) and traumatic strictures (OR: 1.7; p 1⁄4 0.05) were independent predictors for stricture recurrence. Furthermore, distal strictures (b 1⁄4 0.1; p 1⁄4 0.016) and positive urine culture (b 1⁄4 0.1; p 1⁄4 0.012) were independent predictors for increased number of recurrence by linear regression. CONCLUSIONS: obese patients developed post-traumatic strictures at distal anterior urethra are at high risk for recurrence following DVIU. The presence of associated urinary tract infection increases the odds of recurrence frequency.

Many orthopedists looking for alternatives to autograft bone-patellar-tendon-bone grafts are uncertain of their ability to harvest a hamstring graft of adequate length. They may use an allograft instead for this reason despite recent reports of high failure rates. This article presents step-by-step instructions for a posterior mini-incision hamstring harvest that offers a safe and simple method of reliably harvesting sufficient hamstring for 4 or 6 strand repair, while using tiny incisions for excellent cosmesis and minimal pain. Access from the posterior mini-incision allows easy identification and differentiation of the semitendinosus and gracilis (Gr) tendons, as well as precise placement of the anterior mini- incision for tibial tunnel drilling and fixation. Most importantly sectioning of the intertendinous cross-connections is performed under easy direct vision posteriorly, instead of at a distance from the typical anterior incision under retractors. This prevents the tendons from being cut too short by the tendon stripper and is particularly useful in large patients. In addition to the surgical procedure, details on the required equipment are presented.

Purpose: We evaluated the possible use of small intestinal submucosa in endoscopic urological surgery by assessing the smooth muscle regenerative capabilities and physical response of various forms of injectable small intestinal submucosa in the canine model.Materials and Methods: In blinded fashion we injected small intestinal submucosa in 12 dogs submucosally under direct vision using a 20 gauge endoscopic needle. The 4 small intestinal submucosa formulations varied in harvesting method and sterilization technique. Animals were divided into groups of 3 and sacrificed 2 weeks, 6 weeks, 3 months and 6 months after surgery. Each injection site was analyzed grossly and histologically. Smooth muscle regeneration was identified by α-smooth muscle actin immunohistochemical staining.Results: We identified 2 injectable small intestinal submucosa formulations that induced progressive smooth muscle regeneration at the site of submucosal injection compared with controls. De novo smooth muscle cells appeared in sing...

To estimate the incidence of complications of diagnostic and operative hysteroscopic procedures in the Netherlands and describe their nature.Data on complications were recorded by 82 hospitals in 1997. Participating hospitals had a 100% response rate. Any unexpected events that required intraoperative or postoperative intervention were defined as complications in two groups: approach (entry-related) and technique-related (caused by surgical instruments).Thirty-eight complications occurred among 13,600 hysteroscopic procedures (rate 0.28%). Diagnostic hysteroscopic procedures had a significantly lower complication rate (0.13%) than operative procedures (rate 0.95%; P.01). Fluid overloads of distention medium were recorded five times (rate 0.20%). The most frequent surgical complication was perforation of the uterine cavity (rate 0.76%). Approximately half the perforations (18 of 33) were entry-related. Bleeding caused by perforation was seen in 0.16% of cases. Incidences of complications were: intrauterine adhesiolysis 4.48%, endometrium resection 0.81%, myomectomy 0.75%, and removal of a polyp 0.38%.Diagnostic hysteroscopic procedures had very low complication rates, so are safe procedures with which to evaluate intrauterine pathology. Operative hysteroscopic procedures were more risky, but the removal of polyps had a very low complication rate (12 times lower than synechiolysis). Half the complications were entry-related, so attention has to be paid to the method of entry with the hysteroscope (ie, no unnecessary dilation of cervix and introduction of the scope under direct vision). The other half of complications were related to surgeons' experience and type of procedure.

Endoscopic surgery to repair a frontal bone fracture is described. This operation is less invasive than the conventional open technique, which is performed under direct vision through a bicoronal or eyebrow incision. Endoscopic surgery leaves no conspicuous scars in the forehead and is free from complications such as nerve or vascular injuries, and appears to be of significant clinical value.

The existence of numerous techniques for the creation of pneumoperitoneum at laparoscopy indicates that none have been proven totally efficacious or complication free. These methods include the standard technique of insufflation after insertion of the Veress needle via the umbilicus or less commonly via the transfundal or transforniceal routes, open laparoscopy involving dissection through the linea alba and opening of the peritoneum under direct vision, and direct trocar insertion as well as variations on these techniques. After reviewing the methods available and surveying the existing data concerning the rates of failure and complications, we conclude that no single technique can claim to be overwhelmingly superior, and that laparoscopists should, therefore, acquaint themselves with at least two of these techniques. Finally, we recommend a large-scale combined survey by the colleges of obstetricians and gynecologists and surgeons on rates of failure and complications of the varied approaches of abdominal entry for laparoscopy.

In standard techniques for performing ventriculoperitoneal shunts, the peritoneal catheter is threaded more or less blindly into the peritoneal cavity. Using laparoscopic techniques allows accurate peritoneal placement, without a large incision, even in replacement procedures and in patients with previous abdominal operations. We performed 28 laparoscopically guided ventriculoperitoneal shunt placements and shunt revisions in 24 patients with hydrocephalus (aged 6-80 years). Sixteen of 24 patients (67%) had previous abdominal surgery. Laparoscopic shunt placement was successful in all patients. Mean operative time was 63 +/- 34.9 minutes (range 15-150 minutes). In 2 patients, broken and disconnected distal parts of previously inserted shunts were removed from the abdomen. One shunt was removed following infection and other one was revised due to shunt malfunction. Three patients required revision of the cranial part of the shunt. Laparoscopically guided distal ventriculoperitoneal shunt placement provides definite patient benefits: it allows shunt placement under direct vision, associated with reduced trauma to the abdominal wall, and avoids a consequent risk of intra-abdominal adhesions.

Summary: Breast surgery is one of the most frequently performed surgeries in hospitals and can be associated with significant postoperative pain. We report a novel technique of intraoperative lateral pectoral nerve block under direct vision for analgesia post subpectoral implant placement for breast reconstruction.

The esophageal tracheal Combitube® (ETC; Sheridan Catheter Corporation, Argyle, NY) is a twin-lumen tube used to establish emergency ventilation. After blind placement, ventilation is performed via the proximal lumen if it is in the esophagus or via the distal lumen if it is in the trachea. This investigation was designed to test the reliability of the self-inflating bulb (SIB) in identifying the location of the ETC and facilitating its proper positioning in anesthetized patients. In Group I (n=26),the ETC was introduced blindly. In Group 2 (n=20), the tube was placed in the trachea (eight patients) or once in the trachea and once in the esophagus, randomly (12 patients) under direct vision rigid laryngoscopy by the anesthesiologist performing the intubation. In both groups, the efficacy of the SIB in identifying the location of the ETC was tested by a second blinded anesthesiologist. In Group 1, blind insertion of the ETC resulted in esophageal placement in all patients, and in each case was correctly identified. The second anesthesiologist reported no reinflation when the compressed SIB was connected to the distal lumen. When the compressed SIB was connected to the proximal lumen, instantaneous reinflation was observed in 23 patients, delayed reinflation (2-4 s) in two and no reinflation (>4 s) in one patient. Instantaneous reinflation occurred in these three patients after repositioning of the ETC. In Group 2, the second anesthesiologist correctly identified the location of the ETC in all cases. The results confirm previous findings that blind introduction of the ETC leads to esophageal placement and yields adequate ventilation. Furthermore, the SIB can easily and quickly identify the location of the ETC and facilitates its positioning using a simple algorithm. This may be of importance if the ETC is used in patients whose lungs cannot be ventilated by mask and whose trachea cannot be intubated

Inadvertent injuries during trocar and Veress needle placement are a rare but potentially serious complication of laparoscopic surgery. An access alternative is an optical trocar under direct vision. Limited data are available regarding the safety of this technique. We reviewed complications related to optical access trocars during standard transperitoneal urological laparoscopic procedures performed at a single institution.From 1995 to 2001 the optical access trocar was used as the initial trocar in 1,283 urological laparoscopic procedures. The procedures included simple and radical nephrectomy in 309 cases, donor nephrectomy in 386, partial nephrectomy in 79, pyeloplasty in 173 and various other procedures in 336. Intra-abdominal complications caused by optical access trocar were assessed.The optical trocar was inserted at the umbilicus in 88 patients (7.4%), in the right upper quadrant in 445 (34.7%) and in the left upper quadrant in 750 (58.5%). There were 4 injuries (0.31%) associated with the optical access trocar. Complications occurred on the left side in 3 cases and on the right side in 1, including 1 injury to bowel, 1 mesenteric injury resulting in a retroperitoneal hematoma and 2 injuries to epigastric vessels. Three cases were recognized and repaired immediately but in a case of epigastric vessel injury the expanding abdominal wall hematoma required postoperative repair.Optical access trocars provide a safe and rapid technique for initial trocar placement. Results of this large series support the finding that few trocar related complications are associated with the optical access trocar.

Parchment thin skin is a common problem associated with secondary rhinoplasty. When such skin is present, the underlying osseocartilaginous skeleton often becomes visible. Although many techniques have been used to treat the condition, we have found that an onlay graft of temporalis fascia is a most satisfactory method to cover the underlying osseocartilaginous framework or cartilage grafts. Temporalis fascia grafts have been advocated for this purpose in closed rhinoplasty; however, precise placement of the graft is difficult because the graft rolls. On the other hand, when used in open rhinoplasty, the graft may be placed accurately and secured under direct vision. This paper presents our experience with temporalis fascia grafts in open secondary rhinoplasties. Six female patients ages 31 to 57 underwent open secondary rhinoplasty. Five patients also had autologous cartilage grafts. Our average follow-up was 24 months; the minimum was 1 year, and the longest 7 years. All patients had excellent dorsal contours and osseocartilaginous irregularities were not observed. One patient developed a culture-proven nasal infection that responded successfully to antibiotics without removal of the fascia or cartilage graft, a result unlikely to occur when alloplastic materials are used. Biopsy of the temporalis fascia and cartilage grafts was obtained in one patient 12 months after placement. Microscopic examination confirms the long term viability of both grafted tissues, inasmuch as the temporalis fascia was vascularized and normal chondrocytes were present in the cartilage grafts. In summary, we have found that temporalis fascia grafts are a very satisfactory method for managing thin skin in open secondary rhinoplasty.

There have been controversial opinions regarding whether the release of the carpal tunnel should be performed arthroscopically or through an open incision. The authors present a method of open release through a small incision using a set of specially designed instruments, retaining advantages of observing the pathology under direct vision and avoiding complications of hazardous injuries to important structures. The instruments consist of a thin metal guide with a groove in the center to accommodate an angled knife holder. The procedure has been performed since 1997 with no complications.

This multicenter, cooperative study represents the initial United States experience using an expandable, titanium intraprostatic stent in 68 patients (60 to 93 years old). The stents were inserted under direct vision and expanded to 33F using a balloon catheter. All patients had a symptom score analysis, and underwent measurement of peak urine flow and rate and post-void residual urine volume as part of the initial evaluation. Patients were seen at approximately 1, 3, 6 and 18 months after stent insertion (mean followup 16 months). Of the 68 patients 38 presented in urinary retention. The type of anesthesia used included general anesthesia in 6 patients, spinal or epidural anesthesia in 24, intravenous sedation in 20 and intraurethral lidocaine only in 18. All patients were able to void spontaneously within 36 hours after stent insertion. Symptom scores decreased from 16.8 to 3.9, 6.3, 5.0, 5.7 and 3.2 at approximately 1, 3, 6, 12 and 18 months, respectively. Peak urine flow rate increased from 3.9 to 13.8, 11.5, 11.2, 12.4 and 14.4 ml. per second at approximately 1, 3, 6, 12 and 18 months, respectively. Post-void residual urine volume decreased from 74.4 to 30.1, 29.2, 19.8 and 40.2 ml. at approximately 1, 3, 6 and 12 months, respectively. Of the initial 68 patients 5 died of the underlying disorder (all voiding satisfactorily with the stent in place) and 17 underwent uneventful stent removal (10 for technical failure and 7 for treatment failure). Technical failures were secondary to either inaccurate positioning or improper stent sizing. Of the 58 patients with proper placement of the stent and no technical failures 46 (79%) had improvement in symptom scores and urine flow rate. Transient hematuria was noted in 43 patients (63%) and usually resolved within 48 hours. None of the 6 urinary tract infections (9%) was recurrent. In conclusion, the titanium intraprostatic stent, when properly placed, is a promising therapeutic alternative to prostatectomy or long-term catheterization in high risk obstructed patients or those in urinary retention. Studies are currently in progress to determine the long-term efficacy of this therapeutic modality.

Nonvisual laser lithotripsy implies laser fragmentation without the aid of endoscopic or direct vision. Using the laser delivery fiber for retrograde transmission of plasma spectrum and its analysis on an optical multichannel analyzer, we designed a project with the objective of identification and fragmentation of calculi by continuous analysis of the plasma feedback spectrum. We were successful in achieving the objectives in the in vitro and ex vivo studies. In the in vivo studies we successfully recorded the plasma spectrum of the stones from inside the ureter and monitored the process of fragmentation with the laser. We have been able to identify the problems for its clinical application. We conclude that by monitoring the feedback spectrum of plasma emission, nonvisual laser lithotripsy is reliable and safe, and can be used successfully in patients with some modifications. Its development is not to replace established endoscopic lithotripsy procedures but rather as an additional armament for the urologist in special situations. Also, the technique can be further exploited for a variety of clinical uses.

Endopyeloureterotomy has been accepted as a procedure to relieve obstruction of the ureteropelvic junction and upper ureteral stenosis. However, in patients with a long stenotic segment poor results are often obtained with the conventional technique. To resolve this problem we developed a new technique using a 22F urethrotome and a transpelvic extraureteral approach. In this technique the renal pelvis was incised for 1 to 1.5 cm. from the ureteropelvic junction in the direction of the parenchyma using the cold knife of the urethrotome under direct vision. For upper ureteral stenosis the dilated pelvic and ureteral posterolateral walls were incised 1 to 1.5 cm. from the stenotic segment toward the ureteropelvic junction. Then, the stenotic segment was treated with the urethrotome after it was advanced into the retroperitoneal space through the incision in the renal pelvis. We treated 21 patients with the new technique between August 1988 and August 1990. Our series included 3 patients with the high insertion type of ureteropelvic junction obstruction and 4 with a long stenotic segment. The success rate was 95% without any severe complication. These results indicate that our new technique could become a useful procedure for endopyeloureterotomy.

Objective: Evaluation of usefulness and benefits of a new hand-held retractor for minimal invasive technique in cochlear implantation. Setting: Tertiary medical center. Patients: Fourteen consecutive patients (age: 1-83; 4 = female and 10 = male) received a cochlear implant in minimal invasive technique using the new hand-held retractor. Intervention: Standardized operation procedure in minimal invasive technique for cochlear implantation. A short retroauricular incision is used to perform the mastoidectomy with posterior tympanotomy and cochleostomy. Results: The hand-held retractor allows drilling of the bony well for the receiver-stimulator package under direct vision from an anterior position of the surgeon. The sub-periosteal pocket is performed while maintaining continuous suction of irrigating fluids with no further assistance needed. Conclusion: With the new retractor, up to 70% of time to create the bony well is saved compared to previously used instrumentation. The retractor might be further useful in different fields of surgery where the operating field needs to be visualized with the integrated suction and light-device under protection of the surrounding tissue.

A novel method to release the carpal tunnel is presented. It combines the advantages of endoscopic and open techniques while utilizing standard instruments. A lighted Killian nasal speculum is introduced between the palmar fascia and the transverse carpal ligament. The ligament is incised under direct vision. The procedure was performed in 28 cadaver hands and followed by inspection utilizing the open method through an interthenar incision. The transverse carpal ligament was completely divided in all hands without nerve or tendon injury. The superficial palmar arch was injured in one hand (3.6 percent). The advantages, disadvantages, pitfalls, and results are discussed. The technique is simple and effective, employs inexpensive instruments, and has a low complication rate.

A great challenge of rhinoplasty is the tip with insufficient projection or the hooked nose. Tip grafting is the standard method used to correct this. The open rhinoplasty technique provides exposure of nasal structures not afforded by the closed approach. We have used this approach to sculpt the nasal tip. Successful "unhooking of the hooked nose" by gaining tip projection has been achieved by completely replanting the medial crura. In the operation, the medial crura are freed in their entirety. The lateral alae of the lower cartilages are trimmed. The medial crura are then advanced dorsally until adequate nasal tip projection is obtained. They are secured to each other and to the septum in their new position with interrupted sutures. More tip definition can be obtained, if needed, by suturing the medial crura together near the tip. The dome can be sculpted to an appropriate width in a similar manner. This technique is advantageous because exact symmetry and positioning of the cartilages can be obtained under direct vision. It contours the tip structures to achieve more nasal tip projection, obviating the need for tip grafting. The technique is particularly useful in the patient with a low dorsum and acute nasolabial angle who will benefit from tip augmentation and elevation. The technique simultaneously thins the tip, adds nasal tip projection of 4 to 6 mm, and corrects the nasolabial angle. We have used this technique with good results in 15 patients. The technique and results were illustrated.

In 21 revision total hip arthroplasties (THA), a 2-5-cm window was cut into the anterolateral cortex of the femur, and the cement distal to the window was removed under direct vision. In each case, a cemented THA was revised to a noncemented implant that bypassed the window by at least two femur diameters. The section of cortical bone was replaced; autogeneic bone graft was applied to the osteotomy site, and cerclage wires were used to hold the window in place. Postoperatively, all patients were maintained at partial weight-bearing (touchdown) for six weeks and then advanced as they were able. The mean follow-up time in this series was 22 months. Access to the femoral cement was greatly facilitated by the use of a femoral window. There were no intraoperative femoral fractures or inadvertent femoral perforations during cement removal. The mean healing time for the windows was 17 weeks. There was no association of femoral thigh pain or implant loosening with femoral windows. The windows heal rapidly and have not been associated with perioperative femoral fractures.

Use of the open rhinoplasty technique (ORT) in certain nasal and septal deformities has proven to be an invaluable asset in the rhinoplasty armamentarium of the authors. Primarily owing to the markedly increased exposure with this technique, more accurate assessment of the deformities is possible and additional or improved surgical maneuvers become available, particularly in the tip. Sculpting the entire cartilaginous and/or bony vault, as well as correcting difficult septal malalignments, can be carried out under better direct vision with greater precision, accuracy, and predictability. This has led to improved and more consistent final results. Previous criticisms of unsightly columellar scars have been virtually eliminated through the use of improved surgical techniques and simple magnification. Overall, open rhinoplasty technique can provide many distinct advantages in certain nasal deformities with no real disadvantages over conventional closed techniques.

Rigid ureteroscopy is now an established technique for the management of ureteral stones. Manipulation of calculi can be done under direct vision using flexible forceps or stone baskets with increased safety and efficacy. We also have used a 5F electrohydraulic lithotripsy electrode to disintegrate stones that were too large to be removed by manipulation. Between October 1982 and January 1984, 36 ureteroscopies were performed for the removal of ureteral stones. In 26 cases (72 per cent) the stone was removed successfully. Electrohydraulic lithotripsy was used successfully to remove the stone in 9 cases (24 per cent) and there were no immediate complications. Followup with excretory urography in 7 of these patients 2 to 18 months after lithotripsy failed to reveal any evidence of long-term complications. We conclude that electrohydraulic lithotripsy under direct vision can be done safely if certain guidelines are adhered to strictly.

During a 12-year period 57 children presented for treatment of urethral strictures. The patients ranged in age from 2 months to 18 years and there was 1 girl. Of the strictures 8 were congenital, 34 were iatrogenic, 4 were inflammatory and 11 were traumatic. Diagnosis can be suspected from the history and physical examination (observation of the voided stream), and confirmed radiographically and endoscopically. Urethral dilation was definitive treatment in only 28.6 per cent of the patients in whom it was used. Of 4 inflammatory strictures 2 responded to dilation as the only treatment, while only 1 of 5 congenital strictures and 1 of 5 iatrogenic strictures responded to dilation. Direct vision urethrotomy was successful in 1 of 2 congenital and in 5 of 5 iatrogenic bulbar strictures. A 1-stage urethroplasty seems preferable to multistaged procedures, since only 2 of 7 patients managed with staged procedures were treated successfully in 2 operations, while 5 of 9 treated with a 1-stage procedure have required no further intervention.

Twenty-eight patients underwent fiberoptic T-tube tract choledochoscopy for the diagnosis, management, and treatment of filling defects seen on postoperative T-tube cholangiograms. In 22 patients, 59 retained stones were treated by extraction. In six other patients with diagnostic problems arising from cholangiogram defects, the diagnosis was made by direct vision and biopsy specimen examination. There were multiple papillary adenocarcinomas in one patient, and normal mucosal folds in two patients. The procedure was accompanied by a low complication rate, with two patients developing pancreatitis and five patients developing transient fever. The advantages of the procedure are a direct examination of the biliary tree with the facility to remove stones and biopsy lesions under direct vision.

Acute placement of a suprapubic bladder tube followed months later by open urethroplasty has been the traditional manner for managing traumatic disruption of the proximal urethra. The latter procedure has generally been performed via the transpubic or perineal approach. These procedures have been complicated by excessive blood loss, impotence, incontinence, strictures, and extended hospitalizations. Since 1979, 12 patients with obliterated urethras (ten membranous, two bulbous) have been treated by direct vision urethrotomy using a second cystoscope or sound passed through the previously placed suprapubic tract as a guide. Mean blood loss, hospital stay, and followup were 70 ml, 6 days, and 22 months, respectively. Six patients required at least one additional internal urethrotomy. With the exception of one patient who still requires intermittent self-catheterization, all have stable strictures. Ten are continent (one was incontinent secondary to previous radical prostatectomy before urethrotomy and one became incontinent after a TURP performed 3 years after urethrotomy). Five are potent and none lost potency as a result of urethrotomy. Flow rates range from 15-25 ml/second in the continent patients. This is a reasonable first procedure for restoring continuity of traumatically obliterated membranous and bulbous urethras.

Injury to the facial nerve in rhytidectomy has been occurring in less than one percent of the cases, and a spontaneous return of function in more than 80 percent of these injuries has resulted within 6 months. With the introduction of the newer and more aggressive techniques of platysmal and subplatysmal flaps and SMAS dissections, the risk of injury to facial nerve branches is obviously increased. Though there has not yet been an increase in the facial nerve injuries reported, these techniques are still relatively recent additions to the face-lift operation-and usually they have been done by more experienced surgeons, taking more time and working under direct vision with a more careful dissection. More care is needed to prevent injuries. We discuss here the detailed anatomy of the muscular branches of the facial nerve, how to prevent injuries to them during rhytidectomy, and how to manage injuries when they do occur.