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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.

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.

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.

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].

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.

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.

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.

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.

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.

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.

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.

Introduction: VATS lobectomy is a safe and feasible procedure for early-stage non-small cell lung cancer. Despite surgical techniques have become refined and surgical instrumentation becomes more advanced, VATS for advanced-stage lung cancer still controversial. We aimed to evaluate the safety, feasibility, and efficacy of videothoracoscopic lobectomy for primary lung cancer with a diameter of >5 cm. Material and Method: We retrospectively reviewed patient characteristics, surgical procedures, perioperative course, pathological findings, and long-term prognoses of 26 patients who underwent videothoracoscopic anatomical pulmonary resection for primary lung cancer of >5-cm diameter. Results: 550 patients underwent a videothoracoscopic lobectomy for treatment of non-small-cell lung cancer at our center from May 2010 to December 2018. In 26 patients, the tumor was > 5 cm. There were 22 men and 4 women, median age 63,0 years (range: 39 – 78 years). Mean duration of lobectomy was 226,35 minutes, and median duration 212,50(range:135-385) minutes. No patient was converted to conventional open thoracotomy. Mean postoperative stay was 6,3 days and mean drainage duration was 5,8 days. The morbidity rate was 30,7%(%15,5 prolonged air leakage, %7,6 posoperative cardiac arrhythmia, %3,8 postoperative hemorrhage and %3,8 postoperative pneumonia). There were no perioperative and intraoperative deaths. Conclusion: Despite some disadvantages of videothoracoscopic surgery for large lung cancer, like less mobilization of the tumor and a reduced operating space, VATS lobectomy is a safe and technically feasible procedure even in for lung cancer of >5-cm diameter in experienced hands.

The endoscopic enteroenteral bypass could revolutionize the treatment of small bowel obstruction (SBO) in inoperable patients. We describe the technique of endoscopic delivery of a magnetic compression anastomosis device and the creation of an enteroenteral anastomosis in a patient with recurrent acute on chronic SBOs and prohibitively high operative risk. In this novel procedure, a magnetic compression anastomosis device is delivered on either side of the obstruction using a hybrid endoscopic/fluorographic technique, effectively bypassing the obstruction and relieving symptoms. The anastomosis was endoscopically evaluated at regular intervals postprocedure. By 7 days, healthy villi were visible through the mated magnetic rings. By 10 days, the anastomosis was widely patent. The rings passed through the ileostomy and were evacuated, and the patient's symptoms completely resolved. The anastomosis remained widely patent at 1 year. In summary, this case demonstrates the benefit of magnetic compression anastomosis in a patient with SBO and high operative risk.

International audience; Since the early 1970s, total knee arthroplasties have undergone many changes in both their design and their surgical instrumentation. It soon became apparent that to improve prosthesis durability, it was essential to have instruments which allowed them to be fitted reliably and consistently. Despite increasingly sophisticated surgical techniques, preoperative objectives were only met in 75% of cases, which led to the development, in the early 1990s, in Grenoble (France), of computer-assisted orthopaedic surgery for knee prosthesis implantation. In the early 2000s, many navigation systems emerged, some including pre-operative imagery ("CT-based"), others using intra-operative imagery ("fluoroscopy-based"), and yet others with no imagery at all ("imageless"), which soon became the navigation "gold standard". They use an optoelectronic tracker, markers which are fixed solidly to the bones and instruments, and a navigation workstation (computer), with a control system (e.g. pedal). Despite numerous studies demonstrating the benefit of computer navigation in meeting preoperative objectives, such systems have not yet achieved the success they warrant, for various reasons we will be covering in this article. If the latest navigation systems prove to be as effective as the older systems, they should give this type of technology a well-deserved boost.

Optimizing surgical instrumentation may contribute to value-based care, particularly in commonly performed procedures. We report our experience in implementing a perioperative efficiency program in 2 types of orthopedic surgery (primary total-knee arthroplasty, TKA, and total-hip arthroplasty, THA). A comparative before-and-after study with 2 participating surgeons, each performing both THA and TKA, was conducted. Our objective was to evaluate the effect of surgical tray optimization on operating and processing time, cost, and waste associated with preparation, delivery, and staging of sterile surgical instruments. The study was designed as a prospective quality improvement initiative with pre- and postimplementation operational measures and a provider satisfaction survey. A total of 96 procedures (38 preimplementation and 58 postimplementation) were assessed using time-stamped performance endpoints. The number and weight of trays and instruments processed were reduced substantially after the optimization intervention, particularly for TKA. Setup time was reduced by 23% (6 minutes, P = .01) for TKA procedures but did not differ for THA. The number of survey respondents was small, but satisfaction was high overall among personnel involved in implementation. Optimizing instrumentation trays for orthopedic procedures yielded reduction in processing time and cost. Future research should evaluate patient outcomes and incremental/additive impact on institutional quality measures.

This paper is aimed to present a biomaterials perspective in implant therapy that fosters improved bone response and long-term biomechanical competence from surgical instrumentation to final prosthetic rehabilitation. Strategies to develop implant surface texturing will be presented and their role as an ad hoc treatment discussed in light of the interplay between surgical instrumentation and implant macrogeometric configuration. Evidence from human retrieved implants in service for several years and from in vivo studies will be used to show how the interplay between surgical instrumentation and implant macrogeometry design affect osseointegration healing pathways, and bone morphologic and long-term mechanical properties. Also, the planning of implant-supported prosthetic rehabilitations targeted at long-term performance will be appraised from a standpoint where personal preferences (eg, cementing or screwing a prosthesis) can very often fail to deliver the best patient care. Lastly, the acknowledgement that every rehabilitation will have its strength degraded over time once in function will be highlighted, since the potential occurrence of even minor failures is rarely presented to patients prior to treatment.

Video Assisted Thoracoscopic Surgery (VATS) for anatomical lung resection has been performed utilizing 2–4 ports in experienced thoracic surgery centers. The efforts to reduce the number of ports and incision length led to innovations in a uniportal VATS approach. These innovations have gained much popularity over the last decade. The described uniportal technique has disadvantages with regards to surgical instrumentation, ergonomic distribution of the surgical team and how a surgical trainee can be taught. Inspired by our dual port VATS approach and calling upon our experience, we have described a modified uniportal VATS technique. Our new technique also uses a single intercostal space and has potential advantages over the classical uniportal approach with a more stable camera platform, better ergonomics for the surgical team and a more productive experience for the surgeon trainee and surgeon instructor.

Purpose To identify etiology of toxic anterior segment syndrome (TASS) after uneventful phacoemulsification. Setting EyeMD Laser and Surgery Center, Oakland, California. Design Retrospective case series. Methods Patient charts with TASS were reviewed. Reservoirs of 2 autoclaves associated with these cases were cultured for bacterial contamination. Cultures were performed on 23 other autoclave reservoirs at surgery centers in the local area. The main outcome measures were the incidence of TASS and prevalence of bacterial biofilm contamination of autoclave reservoirs. Results From 2010 to 2013, 11 935 consecutive cataract surgeries were performed at 1 center by multiple surgeons with no reported TASS. Between January 1, 2014, and January 15, 2015, 10 cases of TASS occurred out of 3003 cataract surgeries; these patients' charts were reviewed. Cultures of 2 Statim autoclave reservoir walls grew Bacillus species, Williamsia species, Mycobacterium mucogenicum , and Candida parapsilosis . Scanning electron microscopy of reservoir wall sections showed prominent biofilm. The 2 autoclaves were replaced in January 2015. Subsequently, 2875 cataract surgeries were performed with no reported TASS ( P 2 test). Eighteen of 23 additional regional autoclaves were also contaminated with bacterial biofilms. Conclusions Toxic anterior segment syndrome was strongly associated with bacterial biofilm contamination of autoclave reservoirs. An etiological mechanism might involve transport of heat-stable bacterial cell antigens in the steam with deposition on surgical instrumentation. Data suggest widespread prevalence of bacterial biofilms on fluid-reservoir walls, despite adherence to manufacturer guidelines for cleaning and maintenance. Prevention or elimination of autoclave fluid-reservoir biofilms might reduce the risk for postoperative TASS. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Stent migration is an inherent complication of stent deployment. A number of factors are responsible for this dreaded complication. The stent may eventually migrate to the heart or lungs or in the process of migration damage structures en route to its final destination. A number of techniques are available to bail out interventionalists if such a situation should arise. Occasionally a wait and watch approach may be prudent.

The larynx is a highly vascularized organ supplied by the superior and inferior laryngeal arteries. Both microphonosurgery and external laryngeal surgery require excellent hemostasis. Topical agents including adrenalin and fibrin-based products as well as surgical instrumentation, such as coagulation devices or in some cases embolization, are in the surgeon's armamentarium and facilitate efficient and successful surgery.

Traditional open surgical approaches are indicated for treatment of select tumor subsites of head and neck cancer, but can also result in major cosmetic and functional morbidity. Transoral surgical approaches have been used for head and neck cancer since the 1960s, with their application continuing to evolve with the changing landscape of this disease and recent innovations in surgical instrumentation. The potential to further reduce treatment morbidity with transoral surgery, while optimizing oncologic outcomes, continues to be investigated. This review examines current literature evaluating oncologic and quality-of-life outcomes achieved through transoral head and neck surgery.

Category: Ankle; Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis (fusion) is considered a salvage procedure for patients with severe hindfoot and ankle pathology. Several techniques have been described for TTC fusion, including the use of an intramedullary rod, plate and screw constructs, screws only, and external fixation/frames. Recently, 3D printing technology has allowed for a new technique to treat large hindfoot and ankle osseous defects with a custom three-dimensional (3D) titanium truss implant. These implants are specifically designed based on preoperative patient computed tomography (CT) scans. Early studies have shown promising radiographic and functional results, though these have been limited largely to expert opinions and case reports. The purpose of this study is to evaluate the clinical, radiographic, and functional outcomes of TTC arthrodesis using a custom 3D titanium truss implant. Methods: A retrospective review of patients who have undergone TTC arthrodesis utilizing a custom 3D-printed titanium truss implant (4WEB Medical, Inc., Frisco, TX) with a fellowship-trained orthopaedic foot and ankle surgeon at a single institution was performed. Patients Results: Eighteen patients underwent TTC fusion using custom titanium truss implants and were eligible for follow-up and analysis. Average patient age at the time of surgery was 58.7 years, and average BMI was 30.25 kg/m2. Seven patients (38.9%) were either current or former smokers, and 3 patients (16.7%) were diabetic. On average, patient FAAM ADL scores improved from 33.23 preoperatively to 59.56 (p=0.023), while VAS pain scores decreased from 59.07 to 34.22 (pConclusion: We have shown that custom titanium truss implants are viable and effective for use in TTC fusion. Use of such implants resulted in significant functional improvement among the cohort with low rates of complications and subsequent surgical interventions.

The field of reconstructive surgery is rapidly advancing with advances in the techniques of anatomical dissection, understanding of the neurovascular physiology, and improvements in surgical instrumentation. Flaps are composite units of tissue which have their own blood supply or an intact arteriovenous system to receive vascular inflow when transferred to a site of defect. Due to a wide array of flaps being used in reconstructive surgery, numerous terminologies can be found in use by reconstructive surgeons. Skin flaps are flaps that are composed of skin and subcutaneous tissues. Composite flaps are those which contain more than one component within the flap substance, and perforator flaps are those based on a cutaneous perforator. The angiosome concept has aided in understanding the vascular basis of flaps and increases their utility. Further research and insights are needed at the moment to have a finer understanding of the tissue neurovascular anatomy and flap behavior.

Since the advent of modern vitrectomy in the 1970s, a growing and rapidly evolving armamentarium of tools are available to assist the vitreoretinal surgeon. In this chapter, we review modern vitrectomy platforms, traditional and novel methods to visualize the retina such as intraoperative optical coherence tomography (OCT), three-dimensional “heads-up” viewing systems, as well as surgical devices and instruments including drug delivery implants and retinal prostheses.

Osseodensification is a surgical instrumentation technique where bone is compacted into open marrow spaces during drilling, increasing implant insertion torque through densification of osteotomy site walls. This study investigated the effect of osseodensification instrumentation on the primary stability and osseointegration of as-machined and acid-etched implants in low-density bone. Six endosteal implants were inserted bilaterally in the ilium of five sheep totaling 60 implants (n = 30 acid-etched and n = 30 as-machined). Each animal received three implants of each surface. The osteotomy sites were prepared as follows: (i) subtractive conventional-drilling (R): 2 mm pilot, 3.2 mm and 3.8 mm twist drills; (ii) osseodensification clockwise-drilling (CW), and (iii) osseodensification counterclockwise-drilling (CCW) with Densah Burs (Versah, Jackson, MI, USA) 2.0 mm pilot, 2.8 mm, and 3.8 mm multi-fluted tapered burs. Insertion torque, bone-to-implant contact (BIC) and bone-area-fraction occupancy (BAFO) were evaluated. Drilling techniques had significantly different insertion torque values (CCW > CW > R), regardless of implant surface. While BIC was not different as a function of time, BAFO significantly increased at 6-weeks. A significantly higher BIC was observed for acid-etched compared to as-machined surface. As-machined R-drilling presented lower BIC and BAFO than acid-etched R, CW, and CCW. New bone formation was depicted at 3-weeks. At 6-weeks, bone remodeling was observed around all devices. Bone chips within implant threads were present in both osseodensification groups. Regardless of implant surface, insertion torque significantly increased when osseodensification-drilling was used in low-density bone. Osseodensification instrumentation improved the osseointegration of as-machined implants to levels comparable to acid-etched implants inserted by conventional subtractive-drilling.

UNLABELLED ΒACKGROUND: To present surgical instrumentation used in knee chondrectomy and evaluate its effectiveness - a review of the literature. Surgical removal of joint cartilage, or chondrectomy, has been performed by orthopedists since the 1950s. Initially carried out as an open surgery, it has generally come to be performed arthroscopically. Its aim is to create even and stable cartilaginous edges perpendicular to the joint surface and a suitably prepared bottom of the defect for optimum integration of the cartilaginous regenerate. MATERIAL AND METHODS In order to present surgical instrumentation used in knee chondrectomy, English-language journals from the years 2010-2013 with an Impact Factor (2013) of at least 2.0 were analyzed. Papers concerning effectiveness and precision of knee chondrectomy according to the instrument used were also analyzed. RESULTS According to the articles the most popular instruments used to debride chondral defects are open bone curettes (67% of the surgeries), scalpels (35%) and shavers (21%). Open bone curettes were used most frequently in open surgeries (78%), often along with scalpels (49% of the surgeries). In arthroscopic procedures, the most common instruments were shavers (50% of the surgeries) and open bone curettes (49%). CONCLUSIONS 1. In open chondrectomies, the most frequently used instruments are open bone curettes and scalpels. 2. Of all instrumentation presented in this review, this combination ensures the highest precision, as required by Steadman's criteria, of debriding the edges and bottom of a chondral defect. 3. In arthroscopic procedure, a shaver and an open bone curette is the most frequently used combination. 4. None of the instruments and their combinations used in arthroscopic procedure ensures debridement of the defect in compliance with Steadman's recommendations.

Identifying key steps and barriers within complex and simple surgical procedures can be accomplished in a structured and rigorous manner using surgical process modeling. For lower extremity long bone fracture stabilization, the current standard of care is closed intramedullary (IM) nailing, which, despite its widespread use, is associated with challenges that greatly impact operative time and lead to the frustration of medical staff. The aim of this study was to identify challenging surgical steps in IM nailing and understand their underlying causation. Eight semi-structured interviews with staff orthopedic surgeons and eight detailed surgical observations were conducted to understand the surgical steps, challenges and adapted techniques used in IM nailing. Hierarchical decomposition was then utilized to structure the IM nailing surgical procedure into phases, steps and activities. In the developed IM nailing surgical process model, the most challenging steps were identified as fracture reduction (75 %) and entry point selection (25 %), both of which were associated with high levels of frustration in the observed surgeries. Both of these steps utilize 2D fluoroscopic imaging to guide 3D alignment. Challenges arise when the alignment in one plane is lost while adjusting the alignment in the perpendicular plane. This leads to unpredictable repetition of activities which can be time-consuming and frustrating. Identifying the causation of surgical challenges in IM nailing through surgical process modeling forms a knowledge base that can be used to guide future improvements to techniques and surgical instrumentation.

Objectives Autogenous arteriovenous (AV) accesses are the preferred choice for the delivery of haemodialysis (HD). With an increase in the prevalence of end-stage renal disease and in the life expectancy of these patients, the quality and availability of superficial vessels can be limited and reduced with time. The use of prosthetic AV accesses may therefore become necessary for the delivery of HD. A new early cannulation vascular prosthesis (GORE® ACUSEAL Vascular Graft) has been introduced, developed to hinder suture line and cannulation needle bleeding. The authors report their experience with this new conduit at a London teaching hospital. Methods Between May 2011 and June 2013, 52 patients underwent 55 procedures where the ACUSEAL® prosthetic AV access was utilized to facilitate HD. The majority of procedures involved the placement of prosthetic brachio-axillary accesses or prosthetic axillo-axillary chest accesses. Results The 1-year primary and secondary patency was found to be 46% and 61%, respectively. Successful cannulation of the newly placed AV access was performed with 24 hours of surgery in 40 patients (73%). Tunnelled vascular catheters were required in only 10 (18%) patients. Six (11%) of the patients in the study suffered early complications, and 9 (16%) patients developed AV access infection. Conclusions These results show that, while providing patency results that compare favourably to those published for other types of regular prosthetic accesses, the conduits are amenable to very early cannulation with few cannulation-related complications. This leads to a dramatic reduction in the need for temporary or tunnelled catheters.

Arteriovenous (AV) grafts are required for hemodialysis access when options for native fistulas have been fully exhausted, where they continue to play an important role in hemodialysis patients, offering a better alternative to central vein catheters. When planning autogenous accesses using Doppler ultrasound, adequate arterial inflow and venous outflow must be consciously preserved for future access creation with grafts. Efforts to improve graft patency include changing graft configuration, graft biology and hemodynamics. Industry offers early cannulation grafts to reduce central catheter use and a bioengineered graft is undergoing clinical studies. Although the outcome of AV grafts is inferior to fistulas, grafts can provide long-term hemodialysis access that is a better alternative to central venous catheters. AV grafts have significant drawbacks, mainly poor patency, infection and cost but also have some advantages: early maturation, ease of creation and needling and widespread availability. The outcome of AV graft surgery is variable from center to center. The primary patency rate for AV grafts is 58% at 6 months and the secondary patency rate is 76% at 6 months and 55% at 18 months. There are centers of excellence that report a 1 year secondary patency rate of up to 91%. In this review of the use of AV grafts for hemodialysis access in the upper extremities, technical issues involved in planning the access and performing the surgery in its different configurations are discussed and the role of surveillance and maintenance with their attendant surgical and radiological interventions is described.

Since its introduction, unicompartmental knee arthroplasty has been controversial because of poor early clinical outcomes due to implant design, bony fixation, surgical instrumentation, and technique. Improvements in surgical technique and implant design have resulted in improved results and greater survivorship. The ability to obtain accurate implant placement includes avoiding surgeon decisions leading to potential errors. These errors include alignment in the sagittal, coronal, and axial planes on each prepared condyle as well as the preservation of the joint line and the resulting overall limb alignment as something critical to obtaining a successful outcome.

Hemodialysis vascular access is at the same time both the "Lifeline" and the "Achilles Heel" of hemodialysis. This review will initially summarize the vascular biology of dialysis vascular access dysfunction and then use this information to describe some novel and innovative ways (including advances in the process of care for vascular access) to prevent this problem.

Introduction Surgical instrumentation is now available to facilitate wound debridement. The 2 primary options involve different energy applications, but both have the potential to spray. The Versajet II (Smith & Nephew, London, UK) utilizes a high-powered water jet to disrupt tissue and remove debris by means of the Venturi effect. The SonicVac (Misonix, Farmingdale, NY) is a direct-contact, low-frequency ultrasound debriding device. It delivers a high-energy ultrasound to a wound surface via a fluid medium, causing bubble cavitation, a physical effect of rapid pressure waves causing bubbles to form and implode that releases mechanical energy. Objective This study is designed to assess spray dispersion under ideal and challenging conditions. Materials and methods The 2 aforementioned instruments were tested in a laboratory situation. Bacteria (Escherichia coli [ATCC#54288] or Staphylococcus epidermidis [RP62A]) were seeded onto separate pieces of beef steak. Culture plates were set up in a predesignated position around the specimen; the specimen was then treated for 60 seconds at a power setting of 7 and 70% irrigation (ultrasound device) or 10 (waterjet device). After 60 seconds of debridement, about 4 mm to 5 mm of muscle tissue had been removed by the ultrasound device and 2 mm to 3 mm by the waterjet. In the bony specimen, the bone was more exposed after the treatment. The ultrasound device polished but did not remove the bone. Results Both instruments performed well with minimal dispersion in the ideal setting. In beef steak with bone and grizzle, the waterjet created a lawn of bacterial spray in the plate in front of the surgeon. The ultrasound had a small number of contaminants in the same conditions. Conclusions Both instruments can be used safely in the proper conditions, but the surgeon needs to be aware of the limitations and risks of spray dispersion.

Systemic Gardnerella infections are rare and usually associated with surgical instrumentation of the genitourinary tract. We present a case of symptomatic and transient Gardnerella bacteremia in a man with AIDS after a traumatic urinary catheter insertion.

Introduction: Ferromagnetic heating is a new electrosurgery energy modality that has proven effective in hemostatic tissue dissection as well as sealing and dividing blood vessels and vascularized tissue. The purpose of this study was to evaluate a ferromagnetic-based laparoscopic vessel sealing device with respect to sealing and dividing vessels and vascularized tissue and to compare performance against current vessel sealing technologies. Materials and Methods: A laparoscopic vessel sealing device, Laparoscopic FMsealer (LFM), was studied for efficacy in sealing and dividing blood vessels and comparative studies against predicate ultrasonic, Harmonic Ace+(US), and/or bipolar, LigaSure 5 mm Blunt Tip and/or Maryland (BP), devices in vivo using a swine model and in vitro for comparison of seal burst pressure and reliability. Mann-Whitney and Student t test were used for statistical comparisons. Results: In division of 10 cm swine small bowel mesentery in vivo, the laparoscopic FMsealer [12.4±1.8 sec (mean±SD)], was faster compared with US (26.8±2.5 s) and BP (30.0±2.7 s), P240 mm Hg): LFM (1079±494 mm Hg, 98.1% success) versus BP (1012±463, 99.0%), P=NS. For 5 to 7 mm arteries: LFM (1098±502 mm Hg, 95.3% success) versus BP (715±440, 91.8%), P

This letter introduces a single-port robotic platform for transanal endoscopic microsurgery (TEMS). Two robotically controlled articulated surgical instruments are inserted via a transanal approach to perform submucosal or full-thickness dissection. This system is intended to replace the conventional TEMS approach that uses manual laparoscopic instruments. The new system is based on master-slave robotically controlled tele-manipulation. The slave robot comprises a support arm that is mounted on the operating table, supporting a surgical port and a robotic platform that drives the surgical instruments. The master console includes a pair of haptic devices, as well as a three-dimensional display showing the live video stream of a stereo endoscope inserted through the surgical port. The surgical instrumentation consists of energy delivery devices, graspers, and needle drivers allowing a full TEMS procedure to be performed. Results from benchtop tests, ex vivo animal tissue evaluation, and in vivo studies demonstrate the clinical advantage of the proposed system.

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.

The exhaustion of superficial venous patrimony or reduced diameter of superficial veins usually prevents patients from having an arteriovenous fistula created. In such cases, using deep vessels can be a more viable option as opposed to an arteriovenous graft. We describe a new approach for the brachio-brachial arteriovenous fistula creation technique. It consists of 3 small incisions, thus causing minimal surgical damage. We have found it to be better tolerated by the patients and well received by dialysis nurses. This procedure also allows improved access for cannulation and more available puncture sites. info:eu-repo/semantics/publishedVersion

Electromechanical morcellators have come under scrutiny with concerns about complications involving iatrogenic dissemination of both benign and malignant tissues. Although the rapidly rotating blade has resulted in morcellator-related vascular and visceral injuries, equally concerning are the multiple reports in the literature demonstrating seeding of the abdominal cavity with tissue fragmented such as leiomyomas, endometriosis, adenomyosis, splenic and ovarian tissues, and occult cancers of the ovaries and uterus. Alternatives to intra-corporeal electric morcellation for tissue extirpation through the vagina and through minilaparotomy are feasible, safe, and have been shown to have comparable, if not superior, outcomes without an increased need for laparotomy. Intracorporeal morcellation within a containment bag is another option to minimize the risk of iatrogenic tissue seeding. Patient safety is a priority with balanced goals of maximizing benefits and minimizing harm. When intracorporeal electromechanical morcellation is planned, physicians should discuss the risks and consequences with their patients. Although data are being collected to quantify and understand these risks more clearly, a minimally invasive alternative to unenclosed intracorporeal morcellation is favored when available. It is incumbent on surgeons to communicate the risks of practices and devices and to advocate for continued improvement in surgical instrumentation and techniques.

The increased application of the da Vinci robotic platform (Intuitive Surgical Inc.) for microsurgery has led to the development of new adjunctive surgical instrumentation. In microsurgery, the robotic platform can provide high definition 12×-15× digital magnification, broader range of motion, fine instrument handling with decreased tremor, reduced surgeon fatigue, and improved surgical productivity. This paper presents novel adjunctive tools that provide enhanced optical magnification, micro-Doppler sensing of vessels down to a 1-mm size, vein mapping capabilities, hydro-dissection, micro-ablation technology (with minimal thermal spread-CO2 laser technology), and confocal microscopy to provide imaging at a cellular level. Microsurgical outcomes from the use of these tools in the management of patients with infertility and chronic groin and testicular pain are reviewed. All these instruments have been adapted for the robotic console and enhance the robot-assisted microsurgery experience. As the popularity of robot-assisted microsurgery grows, so will its breadth of instrumentation.

The purpose of this retrospective study of 72 dogs was to compare a vessel sealing device with a surgical stapling device for performance of splenectomy. The results of this study demonstrate a statistically significant shorter surgical time for splenectomy, without an adverse effect on outcomes, performed in dogs with the vessel sealing device (mean time, 58.4 min ± 3.3 min; median time, 60 min; range, 22–131 min) compared with a traditional stapling device (mean time, 66.9 min ± 2.4 min; median time, 66 min; range, 40–100 min). No other significant differences were found between the two groups of patients.