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Over the years, surgical therapy for achalasia has been controversial. The controversy has centered on the ideal operative approach, the extent of esophageal myotomy, and the need for the addition of an antireflux procedure. The history of surgical therapy for achalasia is characterized by increasingly more successful and less invasive procedures which have been developed as a direct result of better understanding of (1) the pathophysiology of achalasia, (2) the anatomy of the gastroesophageal junction and the nature of “antireflux barrier”, and (3) advancement in technology in terms of optics, surgical instrumentation, and robotics. The present understanding of the gastroesophageal antireflux barrier has explained the different observations and the discrepancy in the experience of the proponents versus the opponents of an added antireflux procedure to the modified Heller myotomy. Based on this, by nature of not disrupting the three-dimensional relationship at the esophageal hiatus and performing a very careful and limited myotomy on the lateral aspect of the gastroesophageal valve, robotic laparoscopic lateral Heller myotomy preserves the antireflux barrier and accomplishes the goal of the myotomy without the need for an antireflux procedure. This chapter outlines the history of esophageal myotomy for achalasia and elucidates the technique of robotic lateral esophageal myotomy without fundoplication.

Joint realignment has a history dating back to thousands of years. Giant leaps have been taken through the work of some of orthopaedic’s greatest pioneers. Advancements such as the introduction of anaesthesia, the development of aseptic surgical technique and surgical instrumentation, the clinical application of X-rays and its evolution into advanced imaging techniques, refinement in our understanding of limb alignment and fracture fixation and inpatient selection represent some of the cornerstones of what has now become a valuable method of improving pain and function for appropriately selected patients.

Patients undergoing orthopedic surgery are subject to many perioperative insults. Unique to this patient population however is the intravasation of bone, cement, and marrow during the surgical instrumentation process that occurs frequently and may contribute to the pathophysiology of complications seen in the perioperative period. The risk of perioperative complications may be dependent on the level of the operative insult on one hand and end-organ reserve on the other. Identifying interventions that can reduce perioperative insults and instituting programs to identify patients at risk may result in a decrease in the odds for perioperative complications. This chapter explores possible sources of injury and related processes and attempts to relate them to complications frequently seen in orthopedic patients.

Improved efficiency in total knee arthroplasty (TKA) delivery is required to meet the growing demand in a cost-effective manner. Efficiency gains may be realized through standardized clinical care pathways, systems-based organization of operating room throughput, improved surgical techniques, and streamlining surgical instrumentation. This chapter reviews evidence-based strategies in these arenas to improve efficiency in knee surgery.

The transcervical approach to the mediastinum nowadays plays an important role in the diagnosis, staging and treatment of malignant primary and metastatic tumors, benign tumors, mediastinal infections and many other diseases. The advent of endoscopic techniques and dedicated surgical instrumentation has generated new refinements and has expanded the indications beyond the classical mediastinoscopy with very low postoperative morbidity and mortality rates. Thoracic surgeons should be aware of the potential utility of the transcervical approach and be completely familiar with anatomy, technical details, and both classical and new indications of this approach. The goal of this chapter is to provide a concise description of the general methodology and the main technical steps of the transcervical approach to the mediastinum.

The first isolated patello-femoral (PF) joint arthroplasty (PFA) was a patella cap, a Vitallium shell replacing the patella and maintaining the native trochlea, proposed in 1955 by McKeever. The first PFAs replacing entire PF joint had an inlay design and came in the 1979 with the Richards and Lubinus prosthesis. In the last 20 years, I preferred the onlay PFAs, using the inlay designs only in few selected cases. Onlay prostheses completely resect the trochlea with an anterior cut similar to the one performed for total knee arthroplasty (TKA). The Avon (Stryker) and the Zimmer PFJ are examples of onlay prostheses. Second-generation PFAs allow a correction of trochlea rotation or dysplasia and are associated with good results at short-term and midterm follow-up [1]. The enhanced knowledge on PF kinematics, the higher number of component sizes available, the better surgical instrumentation and the easier surgical technique contributed to improve the results. Moreover, early complications like patellar maltracking, instability or catching and snapping of the patellar component during knee flexion were significantly reduced.

The past half century of progress in keratoplasty is reviewed with respect both to fundamental evolution of corneal transplantation from essentially uniform penetrating keratoplasty of the 1960s to the current variations on anterior and posterior lamellar keratoplasty themes. The adjunctive development of surgical instrumentation, eye banking, and tecniques of ocular surface rehabilitation, anterior segment reconstruction and cataract surgery are also interpolated with respect to their influences on keratoplasty itself. The future of bioengineered corneas and their cellular constituents is also introduced.

This chapter introduces the concepts of assessment of cervical deformity as well as planning of cervical deformity (CD) surgery. It highlights the unique characteristics of preoperative analysis indicated in CD surgery to prevent complications. Advances in surgical instrumentation of the cervical spine and anesthesia have facilitated even lengthy surgeries with reproducible results for frail patients in experienced hands. Combined approaches can be necessary to achieve resolution of CD, maintenance of alignment, and fusion on the long-term run. Neuromonitoring is decisive during surgery, as is preoperative medical assessment of the individual patient.

The focus of this chapter will be to introduce the general principles of how operating rooms are designed in order to provide surgical interventions that improve patients’ lives. Although the basic operating room design was first heralded in the nineteenth century, today’s advances have introduced complex surgical equipment that necessitates integration in a fixed space. Moreover, in order to be able to effectively and efficiently carry out a surgical procedure, a highly reliable interdisciplinary and integrated team is necessary. This chapter will provide the reader with a basic overview of the operating room, the key players that work in this environment, and the commonly utilized equipment and instruments.

The reconstructive vaginal set includes specific items in addition to standard surgical instrumentation. This will differ from surgeon to surgeon and is heavily influenced by training. In fact, entering the operative room with surgeons trained in related fields (urology, gynecology, colorectal surgery) or in different training programs will expand one’s repertoire for instrumentation. We would like to call your attention to some particular instruments below.

Endoscopic transsphenoidal pituitary surgery (ETPS) is rapidly replacing both the open transcranial as well as the transsphenoidal microscope-based techniques for resection of pituitary adenomas. This change has resulted from technological advances in lens and camera resolution, minimally invasive surgical instrumentation, and neuronavigation systems, leading to an improved field of view as well as more extensive approaches to skull-base lesions accessed through small portals. Angled endoscopes provide visualization of recesses inside the sella and direct visualization of the medial wall of the cavernous sinus, not accessible by the operating microscope. ETPS is also less invasive, with less postoperative pain, shorter hospitalization, and fewer postoperative complications than microscopic transsphenoidal surgery. The disadvantages include lack of depth perception, the need for an assistant or endoscope holder, and increased incidence of postoperative epistaxis. There is also a steep learning curve, requiring an average of 25–50 operations to learn the techniques necessary to operate using the endoscope. Despite this, experiences with ETPS have largely been positive, with benefits outweighing the costs. In this chapter, we look at the surgical outcomes of functional and nonfunctional pituitary adenomas, and further discuss complications associated with ETPS in general.

Osseointegration of metallic devices has shown to be successful in several biomedical fields. Despite the high success rates, continuous efforts to reduce osseointegration time have been marked by investigations considering a limited number of variables. Recent research has pointed that the interplay between surgical instrumentation and device macrogeometry not only plays a key role on both early and delayed stages of osseointegration but may also be key in how efficient smaller length scale designing (at the micro- and nanogeometrical levels) may be in hastening early stages of osseointegration. The present chapter focuses on how the different metallic device design length scales’ interplay (macro, micro, and nano) affects the bone response and how its understanding may affect the next generation of metallic device designing for osseointegration.

Minimally Invasive Surgery (MIS) represents the gold standard in the majority of abdominal operations, although some fundamental limitations are still present and are far to be really addressed despite emerging robotic solutions. Flexible endoscopes can exploit their high flexibility to reach the surgical target while being inserted remotely or by a natural orifice. However endoscopes may lack stability that rigid tools normally provide. Novel surgical instrumentation is being developed in order to provide higher dexterity and flexibility to the surgeon, but unlike traditional surgical manipulators, here we report the approach followed in the development of the STIFF-FLOP manipulator. The main idea is based on the exploitation of soft materials to be intrinsically flexible and safe while combining different fluidic actuation technologies to enable high dexterity and selective stiffness variability. In this chapter, the functional evolution of the robot is reported highlighting advantages and drawbacks that steered the development of a manipulator which in the end demonstrated to be effective in overcoming mobility limitations experienced with standard rigid tools.

Hip and knee arthroplasty have a big impact on population health and economics due to the large number of procedures and their relative high costs. Joint replacements are complex surgeries, which require skillful surgeons and numerous mechanical instruments. When many such instruments make contact with the patient’s tissue, they are bound to add to the overall infection risk.

High-resolution fiber-optic scopes, powerful Holmium yttrium aluminum garnet (Ho:YAG) lasers, tandem and broad-focused shock wave lithotripters, intricately versatile surgical and endoscopic instruments, and other advances offer minimally invasive and efficacious treatment of urinary tract stones. Even these interventions have a modicum of invasiveness that subjects patients to possible complications. An ideal method for achieving and maintaining stone-free status would rely more on hydration, medicine, and nutrition than on state-of-the-art surgical instrumentation. In this chapter, tailored medical strategies for treatment and prevention of stone disease are discussed.

During my own educational process spanning medical school, orthopedic residency, and a spine surgery fellowship, I never learned much about the sacroiliac joint (SIJ) in terms of functionality and pain generation. I certainly did not learn that people could become functionally disabled with chronic severe pain from a stable appearing SIJ or that fusion surgery could be performed with, at times, almost miraculous results. It was not until I was faced with such a patient that I realized how unequipped I was to both diagnose and treat this problem. As the years past, I began to realize that most surgeons, except for trauma surgeons, were in the same boat as me. Due to the increase in diagnosis of the dysfunctional SIJ and now having surgical instrumentation dedicated to fusing the joint that is all changing. This chapter discusses a few of the urgent considerations for a surgeon embarking on becoming a fuser of the SIJ. These tips have no particular order and will be discussed in various ways throughout this book. I chose to put a chapter together discussing them as a group in hopes that none would be missed from the book altogether as I feel each is important to at least consider.