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BACKGROUND Although abdominoplasty is a mainstay of the plastic surgeon, the safety of the Brazilian butt lift (BBL) has been questioned, effectively being prohibited in some countries. The central rationale for the safety concern over the BBL stems from a publication stating a mortality rate of one in 3000. The question remains: What is the real safety of these procedures? METHODS Focusing on mortality, literature searches were performed for BBL and for abdominoplasty. The 2017 Aesthetic Surgery Education and Research Foundation survey data and publication were examined and analyzed. Additional data from the American Association for Accreditation of Ambulatory Surgical Facilities were obtained independently. RESULTS Abdominoplasty and BBL appear to have similar safety based on mortality; however, the nature of their mortalities is different. Although most abdominoplasty deaths are secondary to deep venous thrombosis/pulmonary embolism-inherent circulatory thrombotic abnormality-BBL mortality is associated with iatrogenic pulmonary fat embolism. BBL mortality rates from more recent surveys on BBL safety demonstrate a mortality of one in 15,000. CONCLUSIONS Although deep venous thrombosis/pulmonary embolism will always remain an abdominoplasty risk, intraoperative BBL pulmonary fat embolism has the potential to be reduced dramatically with a better understanding of dynamic anatomy, surgical instrumentation, and technique. The authors are now presented with a better lens with which to view a more accurate safety profile of BBL surgery, including its place among other commonly performed aesthetic procedures.

Background: Three-dimensional (3D) technologies have numerous medical applications and have gained a lot of interest in medical world. After the advent of three-dimensional printing technology, and especially in last decade, orthopedic surgeons began to apply this innovative technology in almost all areas of orthopedic traumatic surgery. Objective: The aim of this paper is to give an overview of 3D technologies current usage in orthopedic surgery for patient specific applications. Methods: Two major databases PubMed and Web of Science were explored for content description and applications of 3D technologies in orthopedic surgery. It was considered papers presenting controlled studies and series of cases that include descriptions of 3D technologies compatible with applications to human medical purposes. Results: First it is presented the available three-dimensional technologies that can be used in orthopedic surgery as well as methods of integration in order to achieve the desired medical application for patient specific orthopedics. Technology starts with medical images acquisition, followed by design, numerical simulation, and printing. Then it is described the state of the art clinical applications of 3D technologies in orthopedics, by selecting the latest reported articles in medical literature. It is focused on preoperative visualization and planning, trauma, injuries, elective orthopedic surgery, guides and customized surgical instrumentation, implants, orthopedic fixators, orthoses and prostheses. Conclusion: The new 3D digital technologies are revolutionizing orthopedic clinical practices. The vast potential of 3D technologies is increasingly used in clinical practice. These technologies provide useful tools for clinical environment: accurate preoperative planning for cases of complex trauma and elective cases, personalized surgical instruments and personalized implants. There is a need to further explore the vast potential of 3D technologies in many other areas of orthopedics and to accommodate healthcare professionals with these technologies, as well as to study their effectiveness compared to conventional methods.

Summary. The aim. Comparison of clinical, clinical instrumental and morphological data to establish the most informative signs of extremity foreign bodies, the possibility of choosing surgical tactics and improving treatment results. Materials and methods. Removal of ferromagnetic metallic foreign bodies of various sizes was carried out under visual control using a magnetic search tool. Visual control of the removal of a foreign body allows you to assess the adequacy of its removal. Results and its discussion. Removal of a foreign body was carried out using general surgical instrumentation under tactile control using the surgeon's finger and a Billroth curved hemostatic clamp or a mosquito curved hemostatic clamp. Removal of foreign bodies of extremities under hardware control is possible both in continuous time (on line) and intermittent (step-by-step) mode - detection of foreign bodies, marking (leaving marks on the skin). Removal of a foreign body was also carried out under X-ray control. Most often, a step-by-step technique was used, in which the characteristics of a foreign body were first determined, then it was removed and, finally, a control X-ray study was performed with uncertainty about the completeness of removal. In cases where there were problems with the spatial perception of the location of foreign bodies, the removal of foreign bodies under visual, tactile and hardware control was difficult, we used a combination of these methods. Conclusions. As a result of using the proposed modern diagnostic technologies, the completeness of removal of extremities foreign bodies significantly increased from 6.2±0.1 to 1.4±0.1 (p

We aimed to analyze the impact of two different types of surgical instrumentation (conventional manual instrumentation (CI) and patient-specific instrumentation (PSI)) on length of stay (LOS) and objectify differences in cost. We hypothesized that there are no differences in the LOS and cost due to the instrumentation system used.LOS was registered using inpatient admission data provided by the Institutional Management Control Department. We recorded the costs associated with each procedure that could be influenced by the use of one system or another during the in-hospital stay. We conducted a prospectively single-center cohort study of 305 TKAs. Surgery was performed with conventional CI in 122 cases and with PSI in 183 cases.The mean LOS for the CI group was 4.29 days (SD 1.65) and 4.22 days (SD 1.26), for the PSI group. No significant difference among both instrumentation systems was obtained. When comparing global costs, the mean cost was slightly higher (without a significant difference) for the PSI cases (€3110.24 vs. €2852.7 for the CI cases).LOS and overall cost, in hospitals with a low annual TKA surgery volume, are unrelated to conventional or patient-specific instrumentation.

The severe foot and ankle deformities the authors' organization has encountered in humanitarian programs worldwide are more complicated than those surgeons treat in daily practice in developed countries. Severity of deformity, patients' economic limitations, patients' expectations and realistic needs in life, availability of surgical instrumentation, the local team's understanding of foot and ankle surgery and their ability to do consultation for patients postoperatively, and compliance of patients all account for success of the surgery. Regardless of the effort surgeons make, complications and recurrence occur. Educating and training local surgeons to take over medical care are the most important goals of the programs.

Background Surgeons are at high risk of developing musculoskeletal disorders. Study Design This study was designed to identify risk factors and assess intraoperative physical stressors using subjective and objective measures, including type of procedure and equipment used. Wearable sensors and pre- and postoperation surveys were analyzed. Results Data from 116 cases (34 male and 19 female surgeons) were collected across surgical specialties. Surgeons reported increased pain in the neck, upper, and lower back both during and after operations. High-stress intraoperative postures were also revealed by the real-time measurement in the neck and back. Surgical duration also impacted physical pain and fatigue. Open procedures had more stressful physical postures than laparoscopic procedures. Loupe usage negatively impacted neck postures. Conclusions This study highlights the fact that musculoskeletal disorders are common in surgeons and characterizes surgeons’ intraoperative posture as well as surgeon pain and fatigue across specialties. Defining intraoperative ergonomic risk factors is of paramount importance to protect the well-being of the surgical workforce.

There is presently a lack of organization and standardized reporting schema for arteriovenous graft (AVG) infections. The purpose of this article is to evaluate the various types of treatment modalities for access site infections through an analysis of current publications on AVG. Key proposals are made to support standardization in a data-driven manner to make infection reporting more uniform and thereby facilitate more meaningful comparisons between various dialysis modalities and AVG technologies.

OBJECTIVE: Work-related musculoskeletal disorders (WMSDs) among neurosurgeons can lead to consequences for themselves, the hospital, and society. In the current study, the working conditions of neurosurgeons from an ergonomic point of view is evaluated, together with WMSD.METHODS: Members of the Congress of Neurological Surgeons were surveyed with an online survey covering 1) demographics, 2) working conditions, 3) ergonomic features during 3 neurosurgical procedures, and 4) whether they experienced WMSD. Multivariate logistic regression analysis was performed to identify factors associated with experiencing WMSD.RESULTS: hi total, 417 replies were received. Respondents had a mean tenure of 21.9 years. In total, 33.1% stated that the operating room is furnished ergonomically and 90.7% stated that ergonomics is an underexposed field in neurosurgery. The majority of the respondents (73.6%) had experienced WMSD. Performing long procedures and spine surgery were mentioned most often as cause for WMSD. Due to WMSD, 11.3% of the respondents had to take time off work, and 14.2% considered changing their career. Analgesics were mostly used as treatment for WMSD (42.9%) and 7.4% underwent surgery. Having a tenure

INTRODUCTION: Surgical instrumentation in children with adolescent idiopathic scoliosis (AIS) is performed early in life and the implants are left in situ for the rest of the patient's life. Concern has been raised regarding persistent elevated levels of serum metal ions, but only a few studies on the topic have been published. The aim of this study was to compare the levels of serum metal ions in patients with AIS treated with either Harrington rod instrumentation or bracing.MATERIALS AND METHODS: AIS patients treated with Boston brace (BB) or posterior spinal fusion with Harrington rod instrumentation (HR) from 1983 to 1990 were requested to return to clinic. One hundred fifty-nine (73%) of 219 patients were available for follow-up of whom 115 agreed to have a blood draw.RESULTS: The proportion of patients who agreed to have a blood draw were similar in the BB (48 of 100, 48%) and HR (67 of 115, 60%, p = 0.085) groups. None of the surgical patients had their implants removed; mean age at follow-up (BB: 43.2 years vs HR: 43.5 years, p = 0.566) and mean length of follow-up (BB: 26.5 years vs HR: 24.5 years). Mean chromium serum levels were similar between the BB (2.7 nmol/L) and the HR (2.9 nmol/L, p = 0.827). Mean Cobalt serum levels were also similar between the BB (2.6 nmol/L) and the HR (2.8 nmol/L, p = 0.200).CONCLUSION: Serum metal ions were similar in AIS patients treated with bracing or Harrington rod instrumentation 25 years after initiation of treatment.

Introducción: La seguridad del paciente constituye una prioridad en la atención en salud, siendo la lista de verificación para la seguridad quirúrgica una de las estrategias implementadas por la OMS. El objetivo fue determinar el nivel de cumplimiento en la aplicación de la lista de verificación de seguridad de la cirugía en personal de sala quirúrgica de una institución pública. Materiales y Métodos: Estudio de corte transversal en 45 miembros del equipo quirúrgico de un hospital, en los cuales se evaluó el cumplimiento a la lista de chequeo de la OMS durante el mes de julio y agosto del año 2018. Resultados: El cumplimiento global fue del 13.3% (n=6), siendo la fase previa a la anestesia la que alcanzó el mayor nivel (55.6%, n=25). El mayor cumplimiento lo registró el personal de instrumentación quirúrgica (100%, n=8), mientras el más bajo el personal de enfermería (25%, n=3), con diferencias estadísticamente significativas (p=0.005). Adicionalmente, se observó una correlación entre los años de trabajo en el servicio y el cumplimiento en fase de transferencia (rho= -0.30, p=0.048). Discusión: El cumplimiento general fue bajo, lo cual corrobora la hipótesis planteada y resulta similar a otros estudios descritos en la literatura. Conclusiones: El cumplimiento general a la lista de chequeo fue muy bajo, con comportamientos diferenciales al ser las instrumentadoras quirúrgicas las que presentaron mayor cumplimiento y el personal de enfermería el menor. El ítem de profilaxis antibiótica el de menor cumplimiento, mientras que la fase previa a la anestesia la de mayor nivel. Como citar este artículo: Sepúlveda Plata Martha Cecilia. López Romero Luis Alberto. González Sandra Beatriz. Cumplimiento de la lista de verificación de seguridad de la cirugía en un hospital de Santander. Un estudio de corte trasversal. Revista Cuidarte. 2021;12(3):e2122. http://dx.doi.org/10.15649/cuidarte.2122

Transoral robotic surgery (TORS) is an established treatment for many subsites of Head and Neck cancer. With the improved flexibility and access of the single-port (SP) robotic system, tumors within the distal upper aerodigestive tract can now be reached and successfully treated with all the published advantages of transoral endoscopic surgery. Here in we offer the first published surgical technique for SP TORS for resectable hypopharyngeal carcinoma. The video presented demonstrates many important aspects utilizing the enhanced robotic system, including adjustments of the semi-flexible endoscope and use of the third transoral surgical instrumentation. As previously reported, TORS hypopharyngectomy should be considered for resectable tumors to improve upon the deleterious effects of open surgical resection or chemoradiation therapy.

Mohs micrographic surgery, excisional surgery, and electrodessication and curettage (EDC) are common dermatologic procedures that often use electrodessication through hyfrecators to achieve hemostasis. According to in vitro studies, electrodessication is considered safe in patients with implanted cardiac devices. To the authors' knowledge, there are no in vivo data to support this claim.In this study, the authors aim to describe the outcomes of hyfrecation during dermatologic procedures in patients with pacemakers and implantable cardiac devices.Retrospective chart review was completed from March 2014 to April 2018 at a single center. Forty-five patients met criteria of having a cardiac device and having undergone an electrosurgery procedure using the Conmed 2000 Hyfrecator (Utica, NY). Adverse perioperative and postoperative outcomes, as well as device malfunction, were evaluated.No adverse perioperative effects were reported. Device reports were examined for inappropriate firing of the defibrillator, loss of capture, temporary inhibition of pacing, battery drainage, pacing at an elevated or erratic rate, failure to deliver antitachycardia, reversion to asynchronous pacing, induction of arrhythmias, or tissue damage at lead tissue, but no such issues were found.The lack of complications associated with cardiac devices with hyfrecation is reassuring. However, prospective and larger retrospective studies are warranted.

Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2010 to 2015.Investigate which short-term outcomes differ for cervical laminoplasty and laminectomy and fusion surgeries.Conflicting reports exist in spine literature regarding short-term outcomes following cervical laminoplasty and posterior laminectomy and fusion. The objective of this study was to compare the 30-day outcomes for these two treatment groups for multilevel cervical pathology.Patients who underwent cervical laminoplasty or posterior laminectomy and fusion were identified in National Surgical Quality Improvement Program (NSQIP) based on Current Procedural Terminology (CPT) code: laminoplasty 63,050 and 63,051, posterior cervical laminectomy 63,015 and 63,045, and instrumentation 22,842. Propensity-adjusted multivariate regressions assessed differences in postoperative length of stay, adverse events, discharge disposition, and readmission.Three thousand seven hundred ninety-six patients were included: 2397 (63%) underwent cervical laminectomy and fusion and 1399 (37%) underwent cervical laminoplasty. Both groups were similar in age, sex, body mass index (BMI), American Society of Anesthesiologist Classification (ASA), Charleston Comorbidity Index (CCI), and had similar rates of malnutrition, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and history for steroid use. Age more than 70 and age less than 50 were not associated with one treatment group over the other (P 0.05). Compared with laminoplasty patients, laminectomy and fusion patients had increased lengths of stay (LOS) (4.5 vs. 3.7 d, P 0.01) and increased rates of adverse events (41.7% vs. 35.9%, P 0.01), discharge to rehab (16.4% vs. 8.6%, P 0.01), and skilled nursing facilities (12.2% vs. 9.7%, P = 0.02), and readmission (6.2% vs. 4.5%, P = 0.05). Both groups experienced similar rates of death, pulmonary embolus, deep vein thrombosis, deep and superficial surgical site infection, and reoperation (P 0.05 for all).Posterior cervical laminectomy and fusion patients were found to have increased LOS, readmissions, and complications despite having similar pre-op demographics and comorbidities. Patients and surgeons should consider these risks when considering surgical treatment for cervical pathology.3.

The unilateral laminotomy for bilateral decompression initially was described in the late 1990s and has evolved in conjunction with minimally invasive surgical instrumentation. This technique has been shown to significantly improve bilateral symptoms regardless of the side of approach. It also can be used for multilevel decompressions using the slalom technique with alternating lateralizing sites of access. The over-the-top technique involving a unilateral approach for bilateral decompression helps preserve the posterior tension band and can accomplish the operative goals with better clinical outcomes than traditional open approaches.

Background During dissection of paraspinal muscles in posterior surgical approaches, the spine surgeon usually holds a subperiosteal (Cobb) elevator in 1 hand and a monopolar cautery in the other hand. In such a scenario, both the surgical smoke generated by the monopolar and eventual bleeding constitute a significant hindrance to simultaneous bilateral dissection of the paraspinal muscles by 2 surgeons. Methods To address the identified shortcomings in the currently available instrumentation, we initially analyzed the most common surgical techniques employed by residents and fellows at our institution for paraspinal muscle dissection during posterior spinal approaches. Additionally, we collected trainees’ feedback regarding the efficacy of available strategies for dealing with surgical smoke. Results A new coupled Cobb elevator-suction instrument was designed, manufactured, and tested by residents, fellows, and experienced spine surgeons, and small additional design modifications were performed. Conclusions We present what we believe is the first description of a new coupled Cobb-suction instrument that has been developed to enable simultaneous retraction and suction with 1 hand, while allowing the spine surgeon to use the monopolar cautery with the other hand. In our preliminary institutional experience, this new tool has been proven to be especially useful in long posterior spinal approaches in the thoracolumbar region.

Surgery of the petrous apex lesions is considered a surgical challenge. We report our experience and review the literature highlighting current indications and limits in the management of benign and malignant lesions with special focus on the endoscopic approaches. Over the last years, indications and limits of the extended endonasal approaches range from inflammatory disease of the paranasal sinuses to the management of various diseases involving the skull base such as CSF leak, pituitary tumors, ethmoid tumors, petrous apex lesions, and purely intracranial lesions thanks to the development of dedicated surgical instrumentation, the improvement of skull base reconstruction techniques, and a better knowledge of the anatomy. Extended endonasal approach to petrous apex lesions is a safe and effective procedure for appropriately selected patients in the hands of experienced endoscopic skull base surgeons. Nowadays, referral centers equipped by surgical teams with expertise to both endoscopic and lateral skull base routes represent the most safe and effective way of treatment of those diseases.

Innovations in surgical instrumentation and methods are enabling safe and effective minimally invasive options for treatment of many diseases. Similarly, technologic advances in endoscopy are offering assistive devices and techniques to enable more aggressive, yet safe, endoscopic therapies. Endoscopic mucosal resection and submucosal dissection are quickly becoming adopted to offer appropriate patients the least invasive treatment, that is, treatment without surgical scars or approaches. On the horizon at the time of this writing is endoscopic full-thickness resection, which if proven safe has potential to offer the same advantages to a wider variety of pathology. This chapter will focus on a surgeon's perspective of gastrointestinal disease, traditional surgical treatments, and possibilities for these new endoscopic techniques.

Introduction Total hip arthroplasty (THA) is the most common surgery for lower extremities. Improvement in surgical technique and advancement of surgical instrumentation extended the indications for difficult THA in previously impossible to treat. Methods 81 primary THA procedures were performed in Cipto Mangunkusumo National Hospital during the period from January 2012 to June 2017. Subjects consisted of 29 and 52 patients in the difficult and simple group, respectively. Intraoperative parameters including bleeding volume, operation time, complication rate, radiological outcome and functional outcome (Harris Hip Score) were recorded at the end of follow-up and analysed. Results The difficult group had significantly higher bleeding volume (p Conclusions Those with difficult hips did not have significant difference in terms of radiologic and functional outcome compared with the simple hips. It is necessary to identify each primary THA procedures whether there were any, types and levels of difficulties that would be faced intraoperatively in order to improve preoperative planning so the outcome would be optimal.

There are many types of surgical instrumentation and techniques used to perform adenotonsillectomy. The choice of instrument depends on several factors and the benefits of clinical outcomes must outweigh the costs of newer technologies.

This initial version of this treatise was written as I (Curt Tribble) was learning to do coronary anastomoses over 30 years ago, and I worried that I was not being taught very well how go about it doing them. It seemed to me that my teachers were channeling Dr. Alain Carpentier, who often answered questions about his mitral valve repair techniques by saying, “Oh, you just know.” These frustrations were compounded by the fact that the best cardiovascular techniques books, including even those texts dedicated to coronary artery bypass techniques, did not describe these anastomotic techniques in detail, which remains the case to the present day [Kaiser 2007; Copeland 1986].

Nurses and surgeons must identify and handle specialized instruments with high temporal and spatial precision. It is crucial that they are trained effectively. Traditional training methods include supervised practices and text-based study, which may expose patients to undue risk during practice procedures and lack motor/haptic training respectively. Tablet-based simulations have been proposed to mediate some of these limitations. We implemented a learning task that simulates surgical instrumentation nomenclature encountered by novice perioperative nurses. Learning was assessed following training in three distinct conditions: tablet-based simulations, text-based study, and real-world practice. Immediately following a 30-minute training period, instrument identification was performed with comparable accuracy and response times following tablet-based versus text-based training, with both being inferior to real-world practice. Following a week without practice, response times were equivalent between real-world and tablet-based practice. While tablet-based training does not achieve equivalent results in instrument identification accuracy as real-world practice, more practice repetitions in simulated environments may help reduce performance decline. This project has established a technological framework to assess how we can implement simulated educational environments in a maximally beneficial manner.

Purpose The aim of the present study was to systematically analyze how a multifactorial surgical instrumentation approach affects osseointegration on both narrow-diameter and wide-diameter short implants. Materials and Methods Twelve skeletally mature female sheep were used in the study along with 144 plateau-root-form healing chamber titanium (Ti-6Al-4V) implants (Bicon LLC, Boston, MA), evenly distributed between narrow (3.5 mm) and wide (6.0 mm) diameters. The presence or the absence of irrigation, different drilling speeds, and 2 time points quantifying bone-implant contact (BIC) and bone area fraction occupancy (BAFO) to evaluate the osteogenic parameters around the implants. Results There were no signs of inflammation, infection, or failure of the implants observed at either healing period. The narrow 3.5-mm implant, at 6 weeks, yielded significant differences in terms of BIC at a drilling speed of 50 rotations per minute (RPM), with higher values of the samples using irrigation (30.6 ± 6.1%) compared with those without (19.7 ± 6.1%). No statistical differences were detected for 500 and 1,000 RPM with or without irrigation. The wide 6-mm diameter implant showed differences with respect to drilling speed, 500 and 1,000 RPM, with higher values associated with samples subjected to irrigation. BAFO results, for both diameters, only detected statistical differences between the 2 times (3 vs 6 weeks); no statistical differences were detected when evaluating as a function of time, drilling speed, and irrigation. Conclusions Surgical instrumentation variables (ie, drilling speed [RPM] and irrigation) yielded to be more of an effect for BIC at longer healing time (6 weeks) for the wider implants. Furthermore, deploying narrow or wide plateau-root-form implants, where conditions allow, has shown to be a safe alternative, considering the high BIC and BAFO values observed, independent of irrigation.

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.

Management of bleeding is critical for improving patient outcomes. While various hemostatic products are used in daily practice, technical improvement is still needed. To addresses this problem, we newly developed a microneedle hemostatic sheet based on microneedle technology. We demonstrated the unique features of this microneedle hemostatic sheet, including reduced hemostatic time, biodegradable polymer composition that allows intracorporeal use without increasing infectious risk incorporation of microneedles to fix the sheet to the wound even on the left ventricular wall of a swine while beating, and a mesh structure with flexibility comparable to that of bonding surgical tape and sufficient rigidity to penetrate human aorta tissue and swine left ventricular wall. One potential application of the microneedle hemostatic sheet is intracorporeal topical hemostasis for parenchymatous organs, large vessels, and heart wall during trauma or surgery, in addition to new, widespread applications.

Surgeons are often unfamiliar with the costs of surgical instrumentation and supplies. We hypothesized that surgeon cost feedback would be associated with a reduction in cost. A multidisciplinary team evaluated surgical supply costs for laparoscopic appendectomies of 7 surgeons (surgeons A-G) at a single-center academic institution. In the intervention, each surgeon was debriefed with their average supply cost per case, their partner’s average supply cost per case, the cost of each surgical instrument/supply, and the cost of alternatives. In addition, the laparoscopic appendectomy tray was standardized to remove extraneous instruments. Pre-intervention (March 2017-February 2018) and post-intervention (March 2018-October 2018) costs were compared. Pre-intervention, the surgeons’ average supply cost per case ranged from $754-$1189; when ranked from most to least expensive, surgeon A > B > C > D > E > F > G. Post-intervention, the surgeons’ average supply cost per case ranged from $676 to $846, and ranked from surgeon G > D > F > C > E > B > A. Overall, the average cost per case was lower in the post-intervention group ($854.35 vs. $731.11, P < .001). This resulted in savings per case of $123.24 (14.4%), to a total annualized savings of $29 151.

Category: Other; Ankle; Trauma Introduction/Purpose: Little is known about the robotic assistance in the foot and ankle surgery. The present study was to report the robotic arm innovation and its utilization in the foot and ankle surgery. Methods: The robotic arm has been developed to serve for the tasks in foot and ankle surgery. This robot was called as ‘Limb- lifting assistance via robotic arm (LARA)’. It was designed to be a strong base with up and down movement of the trunk using the controller with safe level of electricity to lift its arm to support the ankle or leg during the perioperative period as the surgeon demanded as an attached picture. LARA was prospectively applied in the healthy volunteer and patients with foot and ankle diseases or injuries. The satisfaction levels were collected from the patient and user regarding LARA application. The physical and mental effort levels were also collected from the user during the use of LARA. The related complications were collected in all patients. Results: There were no reported complication from the healthy volunteer. Froma total of 10 patients, there was a scratch at the skin of one patient’s ankle area but it was no need of treatment. Other 9 patients did not report the related complication from the LARA. There was no difference of significant complication between the healthy volunteer and the patients. Based on the data availability, the mean physical and mental effort levels were 5 from 100 (highest level = 100; lowest level = 0). The mean satisfaction level was 100 and 90 from the patient and user perspectives (highest = 100; lowest = 0) respectively. Conclusion: Based on the results of this study, LARA was safe and effective to apply in the perioperative use for the foot and ankle surgeries with low-level of human user effort in both physical and mental aspects.

Objective. Stereotactic technology enables fine navigation to small structures in the human body. While current stereotactic systems facilitate accurate targeting, they are mechanically cumbersome and limited in scope. Here, we hypothesized that a stereotactic system could be developed with a reduced footprint while maintaining broad targeting capabilities in order to improve versatility in frame placement location and surgical workflow. Approach. We designed a stereotactic system around the center-of-arc principle, with mechanical properties that would enable a compact design and ample targeting and trajectory maneuverability. To examine the opportunity for a low-cost rapidly-deployable system we developed two fabrication variants, one using three dimensional (3D)-printing and the other using conventional machining. Mechanical and image-guided accuracies were tested in phantom studies using magnetic resonance imaging (MRI) and computed tomography. Using human cadaver head specimens, we assessed the system’s surgical workflow and its ability to reliably and accurately implant electrodes in deep brain stimulation (DBS) surgery. Main results. We developed a small 7.7 × 5.4 cm2 device platform that rigidly mounts to curvilinear bone and supports the attachment of surgical instrumentation. Attachment of two surgical instruments, an imaging localizer and a compact targeting device, demonstrated successful MRI-guided intervention in phantom studies with a vector error of 1.79 ± 0.41 mm. Evaluation of the 3D-printed system for DBS surgery confirmed ease of device platform attachment and instrument functionality, as well as demonstrated a surgical targeting accuracy of 1.83 ± 0.15 mm. In addition, we found the surgical time to be 78.3 ± 5.4 min for bilateral electrode implantation. Significance. We developed a light and compact stereotactic system whose accuracy is on par with those used clinically. This technology is suitable for clinical translation and its flexibility in positioning will seamlessly expand the capabilities for stereotaxy to treat a wide range of conditions, both within neurosurgery and beyond.

Background Unicompartmental knee replacement (UKR) offers advantages over total knee replacement but has higher revision rates. New instrumentation known as Microplasty was introduced to address this. The aim was to compare the revision rates of UKRs implanted with Microplasty and traditional instrumentation (Non-Microplasty). Methods National Joint Registry (NJR) data was used to propensity score match 15,906 UKRs (7953 Microplasty and 7953 Non-Microplasty) for important patient, implant and surgical factors. Implant survival rates were determined using the Kaplan–Meier method and compared using Cox regression models in a multilevel model. Results The five-year implant survival for Microplasty and Non-Microplasty UKRs were 96.7% (95% CI: 96.0%–97.2%) and 94.5% (CI: 93.8–95.1%), respectively. The revision rate for Microplasty UKR was significantly lower than that of Non-Microplasty UKRs (hazard ratio [HR] = 0.77, p = 0.008). Compared with Non-Microplasty UKRs, the revision rate of Microplasty UKRs implanted during the year after the introduction of Microplasty was lower, but the difference was not significant (HR: 0.86, CI: 0.67–1.10, p = 0.23), whereas for those implanted more than a year after introduction, the difference was significant (HR: 0.69, CI: 0.54–0.89, p = 0.004). Conclusion The use of Microplasty instrumentation has resulted in an improved five-year UKR survival. Microplasty UKR implanted during the first year after introduction had a small, non-significant decrease in revision rate. As the revision rate did not increase, this suggests that there is no adverse learning curve effect. Microplasty UKRs implanted after this transition period had a revision rate 31% lower than the Non-Microplasty group. Level of evidence II.

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.

Health-care-associated infections (HAIs) are a significant problem in all health-care facilities and in all units of the health-care facility. This chapter outlines the scope of the problem with HAIs, types of HAIs, and prevention of HAIs. The chapter discusses the background and history of HAIs. This includes assessing the risk and impact of getting an HAI including multidrug-resistant organisms, patient characteristics, and procedural characteristics. HAIs are categorized as non-device associated, device associated, and surgical site infections. The chapter also looks specifically at device-associated infection. This includes industrial single-use devices such as urinary and intravenous catheters, as well as reusable devices such as surgical instrumentation. In the section on surgical site infection, surgical asepsis and airflow/ventilation are also discussed. The section on preventing HAIs details the steps that can be taken in terms of behavioral, procedural, and engineering solutions. Behavioral solutions include: isolation precautions, surgical hand scrubs, and health-care personnel attire. Procedural solutions include: use of antimicrobials, surgical clippers, postoperative glucose control, postoperative normothermia, WHO Safe Surgery Saves Lives Initiative, and CDC SSI Guideline 1999. Engineering solutions include: suite/room design, protection and barriers, cleaning, disinfection, and sterilization.

Incidence of nasopharyngeal carcinoma (NPC) is on the rise around the globe and more patients are being diagnosed with late-stage disease. Only a minority of patient seek early treatment during early stage disease and tend to have better survival. The survival rates and quality of life (QoL) of NPC patients are intimately related as each can adversely or positively affect one another. Many factors exist at pretreatment, during treatment, and posttreatment that can affect NPC patient prognosis, survival, and QoL. With the emergence of better organ preservation protocols, imaging techniques, surgical instrumentation, and expertise, these NPC patients may have better survival rates and improved prognosis with better QoL.

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.

An innovative surgical magnetic and non‑magnetic instrument was proposed, as well as methods for diagnosing and removal of foreign bodies embedded in soft tissues. The proposed classification of surgical instruments allows to systematize modern approaches to the diagnosis and surgical treatment of gunshot foreign bodies of soft tissues.

Objective The commercially available C-Port distal anastomotic device (Food and Drug Administration cleared in 2007) is an automated miniature vascular stapler that performs the coronary anastomosis. This prospective multicenter registry sought to evaluate midterm patency using this device compared with hand-sewn grafts. Methods Patients receiving at least one C-Port anastomosis during coronary artery bypass grafting surgery were enrolled at eight sites. Of the 117 patients enrolled, 78 patients (67%) with 104 C-Port vein grafts completed the study to patency assessment via computed tomography angiography. Clinical follow-up and index graft patency (Gated 64-slice computed tomography scan) were performed at least 12 months postoperatively. The primary efficacy endpoint was patency compared with the peer-reviewed results from the PRoject of Ex-vivo Vein graft ENgineering via Transfection IV (PREVENT IV) trial. Results The patient population was consistent with the PREVENT IV placebo cohort. The mortality at 12 months was 0.85% (1/117). The major cardiac morbidity rate was 3.4% (4/117). The C-Port vein graft occlusion rate was 16.3% (17/104) compared with 26.6% (597/2242) in the PREVENT IV trial ( P = 0.011). Within this study, C-Port graft occlusion rates were not significantly different from the hand-sewn grafts ( P = 0.821). Conclusions The C-Port device is safe and effective in creating the distal anastomosis with equivalent patency rates to hand-sewn grafts at 12 months. When compared with hand-sewn anastomoses from a recent large prospective trial, the C-Port device demonstrated a statistically significant reduction in midterm graft occlusion. Further studies are required to evaluate its effect in less invasive coronary surgery.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and the treatment options include medical treatment and catheter-based or surgical interventions. AF is a major cause of stroke, and its prevalence is increasing. The surgical treatment of AF has been revolutionized over the past 2 decades through surgical innovation and improvements in endoscopic imaging, ablation technology and surgical instrumentation. The Cox-maze (CM) procedure, which was developed by James Cox and introduced clinically in 1987, is a procedure in which multiple incisions are created in both the left and the right atria to eliminate AF while allowing the sinus impulse to reach the atrioventricular node. This procedure became the gold standard for the surgical treatment of AF. Its latest iteration is termed the CM IV and was introduced in 2002. The CM IV replaced the previous cut-and-sew method (CM III) by replacing most of the incisions with a combination of bipolar radiofrequency and cryoablation. The use of ablation technologies, made the CM IV technically easier, faster and more amenable to minimally invasive approaches. The aims of this article are to review the indications and preoperative planning for the CM IV, to describe the operative technique and to review the literature including comparisons of the CM IV with the previous cut-and-sew method. Finally, this review explores future directions for the surgical treatment of patients with AF.

Study DesignExperimental Animal Model.PurposeThe aim of our study was to validate a pure bilateral ovariectomy (OVX) female New Zealand white rabbit model of postmenopausal osteoporosis utilizing animal-sparing in vivo techniques for evaluating bone mineral density (BMD). We also sought to demonstrate that bilateral OVX in female New Zealand white rabbits can produce diminished BMD in the spinal column and simulate osteoporosis, without the need for adjuvant chemotherapeutic agents (i.e., no additional glucocorticosteroids or other drugs were used for stimulating accelerated BMD loss), which can be assessed by in vivo BMD testing.Overview of LiteratureMultiple animal models of postmenopausal osteoporosis have been described. Rat ovariectomy models have been successful, but are limited by rats' inability to achieve true skeletal maturity and a slight morphology that limits surgical instrumentation. Rabbit models have been described which do not have these limitations, but previous models have relied on adjunctive steroid therapy to achieve osteoporosis and have required animal sacrifice for bone mineral density assessment.MethodsThirty-six skeletally mature female rabbits underwent bilateral OVX. BMD was measured using dual-energy X-ray absorptiometry on the metaphysis of the proximal tibia and distal femur, at baseline and 17 weeks postoperatively.ResultsMean BMD values were significantly reduced by 21.9% (ppConclusionsThis study is the first to demonstrate a significant bone loss within four months of pure OVX in rabbits using animal-sparing validation techniques. We believe that this OVX model is safe, reproducible, and can be employed to longitudinally evaluate the effect of anti-osteoporosis therapeutics and surgical interventions.

Summary Aim To standardize and reduce surgical instrumentation by >25% within a 9-month period for pediatric inguinal hernia repair (PIHR), using “improvement science” methodology. Methods We prospectively evaluated instruments used for PIHR in 56 consecutive cases by individual surgeons across two separate subspecialties, pediatric surgery (S) and pediatric urology (U), to measure actual number of instruments used compared with existing practice based on preference cards. Based on this evaluation, a single preference card was developed using only instruments that had been used in >50% of all cases. A subsequent series of 52 cases was analyzed to assess whether the new tray contained the ideal instrumentation. Cycle time (CT), to sterilize and package the instruments, and weights of the trays were measured before and after the intervention. A survey of operating room (OR) nurses and U and S surgeons was conducted before and after the introduction of the standardized tray to assess the impact and perception of standardization. Results Prior to creating the standardized tray, a U PIHR tray contained 96 instruments with a weight of 13.5 lbs, while the S set contained 51, weighing 11.2 lbs. The final standardized set comprised 28 instruments and weighed 7.8 lbs. Of 52 PIHRs performed after standardization, in three (6%) instances additional instruments were requested. CT was reduced from 11 to 8 min (U and S respectively) to Conclusions Standardization of surgical equipment can be employed across disciplines with the potential to reduce costs and positively impact quality, safety, and efficiencies.

Translation of optical coherence tomography (OCT) technologies for intraoperative visualization enables in vivo micron-resolution imaging of subsurface tissue structures and image-guided clinical decision-making. Over the last decade, intraoperative OCT has evolved from two-dimensional imaging using handheld probes to include biopsy-needles for minimally invasive deep-tissue imaging, surgical instrumentation using optical feedback for tremor dampening and stabilization, and stereomicroscope integrated systems that provide real-time three- and four-dimensional visualization of surgical maneuvers. In addition, several preliminary studies have demonstrated the feasibility and utility of combining intraoperative OCT imaging with novel image-processing and display methods to implement augmented/virtual reality and robotic surgical guidance platforms. While research and commercialization of these innovations have been largely driven by needs in ophthalmology, OCT is finding new clinical applications in surgical oncology and neurosurgery. In this paper, we review recent developments in intraoperative OCT and discuss current trends and future directions of the technology.

In the perioperative environment, communication, safety, and efficiency are paramount to ensure the effective delivery of patient care. Often overlooked, however, is the role that surgical instrumentation plays in these aspects of perioperative care. Through an analysis of the sterile processing environment at Massachusetts General Hospital (MGH), we identified a large amount of instrumentation being cycled unnecessarily throughout the system. This pattern was particularly notable for laparotomic equipment that is sent to almost all laparoscopic cases so that it is available in the event of conversion to laparotomy. Prompted by this analysis along with the high case volume and low conversion rate of laparoscopic cholecystectomies and appendectomies, we redesigned the laparotomic instrument supply chain for these procedures by placing all laparotomic conversion instruments on dedicated emergency case carts. In one month following implementation we avoided cycling nearly 15,000 pounds of unused instrumentation through the perioperative environment and have increased staff safety and communication among perioperative leadership. Objective to reduce the amount of unnecessary surgical instrumentation that is cycled through the perioperative environment.

Introdução: Complicações biliares ocorrem em 10% - 30% dos transplantes hepáticos. O objetivo deste trabalho é comparar as incidências dessas complicações nos transplantes hepáticos em que foi ou não utilizado tubo em T na anastomose biliar.Material e Métodos: Análise de dois grupos de doentes submetidos a transplante hepático entre 2008 e 2012. Consideraram-se os doentes em que o tubo em T foi utilizado (G1) e em que não o foi (G2). Procuraram-se depois modelos explicativos da ocorrência de complicações biliares por regressão logística, incluindo as variáveis identificadas na análise univariável.Resultados: Estudaram-se 506 doentes consecutivos submetidos a um primeiro transplante hepático (G1 = 363; G2 = 143). A incidência global de complicações biliares foi 24,7% (IC 95% 21,1 - 28,6): 27,0% no G1 e 18,9% no G2 (p = 0,057). As incidências de estenose e de fístula biliar foram tendencialmente mais elevadas em G1: 19,6% (IC 95% 15,7-23,8) vs 15,4% (IC 95% 10,1 - 22,0) (p = 0,275) e 6,6% (IC 95% 4,4 - 9,5) vs 2,8% (IC 95% 0,9 - 6,6) (p = 0,091). Não se encontraram diferenças estatisticamente significativas nas taxas de colangiopancreatografia retrógrada endoscópica, reoperação e retransplante. Verificaram-se dois óbitos no G1. Não se encontrou associação entre a ocorrência de complicações biliares e os diâmetros das vias biliares ou o tempo de isquemia fria. O modelo explicativo ajustado à idade do recetor e do dador, e ao diagnóstico de base identifica o uso do tubo em T como aumentando a possibilidade da ocorrência de complicações biliares (AdjOR 1,71; IC 95% 1,04 - 2,80; p = 0,034).Discussão e Conclusão: A utilização do tubo em T deve ser uma decisão tomada caso a caso e baseada no julgamento intra-operatório de cirurgiões experientes.