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The risk for patients during the standard procedure of revision of cemented artificial hip joints is unsatisfactorily highdue to its high level of invasiveness and limited access to the operative field. To reduce this risk we are developing anImpedance Controlled Surgical Instrumentation (ICOS) system, which aims to establish real-time control during a BoneCement (BC) milling process. For this, the relationship between the thickness of the BC and its frequency-dependentelectrical impedance is used to estimate the residual BC thickness. The aim is to avoid unintended cutting of boneby detecting the passage of the BC/bone boundary layer by the milling head. In a second step, an estimation of theresidual BC thickness will be used to improve process control. As a first step towards demonstrating the feasibility ofour approach, presented here are experimental studies to characterize the BC permittivity and to describe the process indetail. The results show that the permittivity properties of BC are dominated by its polymethyl methacrylate (PMMA)fraction. Thus, PMMA can be used as a substitute for future experiments. Furthermore, a Femoral Test Bed (FTB) wasdesigned. Using this setup we show it is feasible to accurately distinguish between slightly different thicknesses of BC.

Background. Abnormal spinal curvature is routinely assessed with plain radiographs, MDCT, and MRI. MDCT can provide two-dimensional (2-D) orthogonal as well as reconstructed three-dimensional volume-rendered (3-D VR) images of the spine, including the translucent display: a computer-generated image set that enables the visualization of surgical instrumentation through bony structures. We hypothesized that the 3-D VR series provides additional information beyond that of 2-D orthogonal MDCT in the evaluation of abnormal spinal curvature in patients evaluated at a major cancer center. Methods. The 3-D VR series, including the translucent display, was compared to 2-D orthogonal MDCT studies in patients with an abnormal spinal curvature greater than 25 degrees and scored as being not helpful (0) or helpful (1) in 3 categories: spinal curvature; bony definition; additional findings (mass lesions, fractures, and instrumentation). Results. In 38 of 48 (79.2%) patients assessed, the 3-D VR series were scored as helpful in 63 of 144 (43.8%) total possible categories (32 spinal curvature; 14 bony definition; 17 additional findings). Conclusion. Three-dimensional MDCT images, including the translucent display, are complementary to multiplanar 2-D orthogonal MCDT in the evaluation of abnormal spinal curvature in patients treated at a major cancer center.

An innovation in surgical instrumentation for performing endoscopic suturing was applied in 15 patients who underwent a laparoscopic approach to the traditional retropubic modified Burch procedure.

The mean forces required to dislodge two types of endoscopic ligation clips from both porcine cystic ducts and silicone tubing were quantitated. The two types of endoscopic clips were EndoClip II and Ligaclip ERCA. Following application of the clips, the force required to dislodge the clips in both a perpendicular direction and a longitudinal direction was determined. The mean levels of force required to dislodge the EndoClip II clips in both directions were significantly (p ≤ 0.01) greater than those required to dislodge the Ligaclip ERCA clips.

SummaryThe indication for thoracoscopic surgery has expanded with advances in endoscopic surgical instrumentation. Thoracoscopic treatment of intrathoracic neurogenic tumour was performed in five patients: three tumours arose from the sympathetic chain with no intraspinal extension, one from the vagus nerve and one from the intercostal nerve. Of the five tumours, two were located in the superior mediastinum, two in the posterior mediastinum and one in the chest wall. Mean operation time and estimated blood loss were 161 min and 39 g, respectively. In all five patients, the chest tube was removed within 48 h of operation and there were no complications related to the thoracoscopic surgery. We conclude that thoracoscopic surgery should be considered for the treatment of intrathoracic neurogenic tumours which occur in adults and show no intraspinal extension.

Introduction. While experimental natural orifice transluminal endoscopic surgery (NOTES) sigmoid colectomies have been reported, pure NOTES anastomoses are restricted by the limited reach of commercially available circular staplers. MAGNAMOSIS is a set of self-orienting magnetic rings that can be delivered endoluminally throughout the colon to generate a compression anastomosis. Aim. To assess the feasibility of a pure NOTES transrectal (TR) and transgastric (TG) approach to perform any segmental colectomy. Materials and Methods. One pig (50 kg) underwent the experimental procedure as follows: ( a) creation of the TG access to the peritoneal cavity, ( b) precise transluminal placement of the proximal MAGNAMOSIS ring, ( c) creation of the TR access with the TEO and transrectal dissection of the sigmoid mesentery, ( d) resection of the surgical specimen, ( e) transrectal extraction of the specimen, ( f) delivery and mating of the distal MAGNAMOSIS ring, and ( g) closure of the TG and TR viscerotomies. The animal survived for 14 days at which time burst pressure and histology were performed. Results. A pure NOTES TR and TG segmental colectomy was performed in 139 minutes. The postoperative course was uneventful. The animal had a formed bowel movement including the magnetic rings on postoperative day 5. Endoscopic examination at postoperative day 14 revealed a patent anastomosis. Necropsy revealed no abscess or signs of peritonitis. Burst pressure was >198 mm Hg. The histology showed a sealed anastomosis with mild inflammation. Conclusions. MAGNAMOSIS enabled a totally NOTES partial colectomy with combined TG and TR access. The flexible delivery options and low cost of manufacturing could make MAGNAMOSIS an attractive alternative to circular staplers.

✓ The authors have developed, in dogs, a nonsuture vascular anastomosis utilizing plastic adhesive and a water-soluble spindle tube composed of 80% saccharose, 16% glucose, and 4% dextrin. The patency rate of end-to-end arterial anastomosis was 70% in arteries with an external diameter of 2.5 to 4.0 mm. The device is easily applied, saves time, and does not require any special instruments.

Advances in anatomical knowledge, progress in surgical instrumentation, and innovative surgical techniques have significantly changed soft tissue reconstruction of the hand. Continual improvements in design and harvesting techniques have led to flap refinements, resulting in improved aesthetic and functional results following soft tissue reconstruction. This holds true for microsurgical free flaps, as well as for regional flaps, such as the intrinsic flaps in the hand. Soft tissue defects of the fingers resulting in exposed tendons, bones, or joints are frequently encountered in hand surgery. Reconstruction can be challenging if the principle of replacing like withlikeisfollowed.Extensiveliteratureisavailable concerning the variety of local and regional flaps that may be used for coverage of these defects. Intrinsic flaps in the hand can be classified by Vascular anatomy (axial/random pattern) Donor site location Perfusion pattern Tissue components included. Following descriptions by Littler 1 and Bunnell, 2 soft tissue reconstruction in the hand was limited to a small variety of flaps, often resulting in unsatisfactory results, due to considerable donor site morbidity and long rehabilitation times. This changed with the first descriptions of dorsal

Continual innovations in surgical technologies are pushing the limits of what surgeons can achieve. No-scar surgery, a technique of performing intra-abdominal surgery by accessing through natural o...

A novel surgical technique and novel surgical instrumentation for closing a pupil defect in a closed chamber eye is described. The technique was performed in a laboratory setting using ex-vivo porcine eyes using a 30-gauge deployment system to repair iris defects. Given the difficulty of suturing in a closed chamber eye, the use of an injectable, shape memory alloy clip offers the advantages of rapid, easy deployment and increased strength over conventional suture techniques.

Stapled pulmonary tractotomy with selective vascular ligation is a rapid technique used to control hemorrhage in penetrating pulmonary injuries and has assumed an important role in the trauma surgical armamentarium for the management of these injuries. This technique was designed as tissue sparing to avoid complications well known to occur with extensive pulmonary resections. Multiple studies have validated and reported this technique to be both safe and effective. Here we present the use of the argon beam coagulator as a valid adjunct to stapled pulmonary tractotomy for the management of penetrating pulmonary injuries. To our knowledge, the use of this technique has not been reported for control of massive intraparenchymal pulmonary hemorrhage.

There have been major advances in the treatment of rectal cancer in the last two decades. Improvements in surgical instrumentation has dramatically impacted the surgical approach to rectal cancer. Particularly laparoscopic procedures have been assumed a central role in the management of benign and malignant colorectal diseases as a result of a recent paradigm shift toward minimally invasive surgery. The reasons include faster recovery times with reduced hospital stay, fewer wound-related complications, better cosmesis and oncological outcomes identical to the open traditional procedures (1,2). Although conventional laparoscopic surgery (CLS) is less traumatic than open surgery, it still continues to be associated with tissue trauma due to the size and the number of ports, each at least 1-2 cm in length (3,4). Each incision carries potential morbidity risks of bleeding, visceral organ damage, pain and formation of incisional hernia. Morover the small incisions performed for trocar placement may results in multiple scar formation and compromised cosmetic outcome (5). Single-port access (SPA) or single-incision (SILS) laparoscopic surgery has been developed as a new alternative to conventional laparoscopy. SILS technique uses a solitary incision with a specialised multilumen (3-4) port and curved or articulated instruments. This surgical innovation obviates the need for triangulation, a fundemantal requirement of conventional laparoscopy, thus minimising the number of ports. SILS surgery is emerging as a method to help decrease morbidity, optimize the cosmetic benefits of CLS and minimize the surgical trauma. Early clinical series with various procedures have demonstrated not only the feasibility but also the safety of the SILS surgery (6,7). Recently, there is an increasing trend toward the application of SILS surgery in complex abdominal operations (8). Although there has been published accounts of SILS laparoscopic colon resections and some cases of proctocolectomy and total colectomy (9-16) the literature regarding SILS laparoscopic surgery for rectal cancer is currently very rare (17,18). This is probably due to the technical challenges of the rectal dissection and to the fact that the evidence for the use of CLS in the setting of rectal cancer is limited when compared with colon cancer. This chapter will outline the current evidence for SILS as a treatment option for patients with rectal cancer and highlight the technical details of different procedures in rectal surgery.

Although the concept of endoscopy has existed for centuries, a practical, working neuroendoscopic system did not emerge until last century, as a result of numerous contributions and refinements in optical technology, illumination sources, and instrumentation. Modern neuroendoscopy would not be a flourishing field, as it is today, without the dedication, innovation, and implementation of emerging technology by key contributors including Maximilian Nitze, Walter Dandy, and Harold Hopkins. Despite several inherent and unique limitations, neuroendoscopic surgery is now performed for a variety of intraventricular, skull base, and spinal operations. In this review, the history of neuroendoscopy, key players who envisioned how the inner workings of the human body could be visualized "through the looking glass," and current state and future potential for neuroendoscopic surgery are discussed. Future directions of neuroendoscopic surgery will likely be guided by further miniaturization in camera and optical technology, innovations in surgical instrumentation design, the introduction of robotics, multi-port minimally invasive surgery, and an enhanced ability to perform bimanual microdissection.

Objective: Review a series of patients with Zenker diverticulum who were treated with endoscopic diverticulostomy using Harmonic Ultrasonic Surgical Instrumentation (Ethicon Endosurgery, Cincinnati, Ohio) in order to evaluate the safety and optimal application of this technology to the treatment of patients with this disorder.Method: Retrospective chart review of patients undergoing endoscopic surgical correction of Zenker diverticulum with Harmonic Ace curved shears between July 1, 2009 and November 1, 2010. Presenting symptoms, size of diverticulum, operative times, length of hospital stay, outcomes, and complications were reviewed.Results: A total of 60 endoscopic diverticulostomies were performed, and 24 were Harmonic-assisted. Eight required hospital stays, with their average stay being 2.13 days (0.7 days for all Harmonic patients). There were 6 complications with Harmonic treatments (25%). Two patients had chest pain with negative work-ups. Two patients had subcutaneous air. One had a documented sa...

Surgical instrumentation for adolescent idiopathic scoliosis (AIS) is a complex procedure where selection of the appropriate curve segment to fuse, i.e., fusion region, is a challenging decision in scoliosis surgery. Currently, the Lenke classification model is used for fusion region evaluation and surgical planning. Retrospective evaluation of Lenke classification and fusion region results was performed.Using a database of 1,776 surgically treated AIS cases, we investigated a topologically ordered self organizing Kohonen network, trained using Cobb angle measurements, to determine the relationship between the Lenke class and the fusion region selection. Specifically, the purpose was twofold (1) produce two spatially matched maps, one of Lenke classes and the other of fusion regions, and (2) associate these two maps to determine where the Lenke classes correlate with the fused spine regions.Topologically ordered maps obtained using a multi-center database of surgically treated AIS cases, show that the recommended fusion region agrees with the Lenke class except near boundaries between Lenke map classes. Overall agreement was 88%.The Lenke classification and fusion region agree in the majority of adolescent idiopathic scoliosis when reviewed retrospectively. The results indicate the need for spinal fixation instrumentation variation associated with the Lenke classification.

Objectives/Hypothesis: To evaluate the efficacy of image-guided surgical navigation (IGSN) in otologic surgery and establish practice guidelines. Study Design: Prospective study. Methods: Between January 2003 and January 2010, all patients requiring complicated surgery for chronic otitis media, glomus jugulare, atresia, cerebrospinal fluid leak with or without encephalocele, and cholesterol granuloma of the petrous apex were offered IGSN. The accuracy of IGSN relative to pertinent pathology and 11 anatomic landmarks was established. Additionally IGSN-related operative time, complications, and surgical outcome were recorded. Results: In the study period there were 820 otologic procedures, among 94 patients (96 ears) with disease meeting proposed criteria. Thirteen patients (15 procedures) consented to the use of IGSN. All patients had a minimum 6 months of follow-up. The average additional operative time required was 36.7 minutes. The mean accuracy error was 1.1 mm laterally at the tragus but decreased to 0.8 mm medially at the level of the oval window. The mean accuracy of IGSN was within 1 mm in 10 of the 11 targeted surgical anatomic landmarks. Conclusions: Interactive image-guided surgical navigation during complex otologic surgery may improve surgical outcome and decrease morbidity by providing an accurate real-time display of surgical instrumentation relative to patient anatomy and pathology. In select cases, the extra cost of imaging immediately prior to surgery and extra operating room time may be compensated by enhancing the ability to distinguish distorted anatomy relative to disease, potentially improving surgical outcome. IGSN, although useful, does not replace surgical expertise and experience.

The purpose of the current prospective, randomized study was to compare the value of a new mechanically aligned patient-matched instrument system for total knee arthroplasty (TKA) (Visionaire; Smith & Nephew, Inc, Memphis, Tenn) (VIS) to that of standard TKA surgical instrumentation (STD). Twenty-nine primary TKA patients were enrolled and completed surgery (15 VIS and 14 STD). Postoperatively, mechanical alignment was significantly closer to neutral zero in the VIS group (1.7° vs 2.8°; P = .03). Furthermore, the VIS group demonstrated significant reductions in duration of hospital stay, operative time, incision length, and number of used instrument trays (P < .05). Although additional research is underway to confirm these preliminary results, this evidence suggests that patient-matched instrumentation may support repeatable improvements in surgical accuracy and hospital efficiency.

Purpose of review Thoracic empyema is the accumulation of frank pus within the pleural cavity. Its cause is often multifactorial and may include direct contiguous spread of infection, penetrating chest trauma or an iatrogenic cause secondary to surgical instrumentation of the pleural space. Current management of empyema is based on local empirical practice as there is no consensus on an optimal regimen. Over the past decade, surgical management of empyema has attracted great interest, leading to specific recommendations. Recent findings Video-assisted thoracoscopic surgery (VATS) has revolutionized surgical management of patients with empyema. Thoracoscopic management of empyema includes VATS debridement and decortication. VATS debridement has been employed by many centres as the primary treatment option for early-stage empyema. However, this is still contentious as some surgeons continue to advocate initial trials of chest tube drainage and antibiotic-mediated pleural space obliteration prior to any form of surgery. A more aggressive approach is to move directly to VATS decortication, which has shown great promise in the management of chronic empyema. More complex, mulitloculated empyemas would previously have been managed solely by complex open surgical procedures such as open window thoracostomy or thoracomyoplasty. However, recent studies have shown VATS decortication to produce equivalent resolution rates to the higher morbidity open approaches. Summary A summary of the most recent opinions and results in the thoracoscopic and open surgical management of thoracic empyema is outlined. Early VATS debridement effectively manages simple parapneumonic effusions. VATS decortication has equivalent efficacy to open decortication at managing both chronic and early-stage empyemas.

Surgical instrumentation and fusion is currently the definitive treatment for children with spinal deformities. Although midterm follow-up studies with modern instrumentation systems and techniques have demonstrated satisfactory outcomes in terms of deformity correction, maintenance of correction, and patient satisfaction, it is well accepted that spinal fusions sacrifice spinal flexibility, alter stresses on adjacent unfused segments, and may lead to problems with spinal imbalance in the long term [9, 19, 20, 26, 29, 40].

Although modern operative neurosurgery is a complex technical undertaking requiring an amalgam of technologies and instrumentations, few reported efforts have dealt with the definition and development of suitable and optimal dedicated operating environments. This report presents the first detailed description of a dedicated, self-contained neurosurgical operating suite incorporating major surgical instrumentation and visualization technologies to provide an "idealized" environment for stereotactic, microscopic, and microstereotactic procedures. Advanced computer technology for visualization to augment, simulate, document, and facilitate all aspects of neurosurgery is described. The architectural and functional design of the operating suite is itself an integral surgical instrument as well as a laboratory for development of new dimensions of neurosurgery.

The role of operative staging of patients with Hodgkin's disease continues to evolve. First described in 1969, the indications for this procedure continue to be redefined. Recent advances in surgical instrumentation have allowed procedures such as cholecystectomy, colon resection, nephrectomy, and splenectomy to be performed laparoscopically. We report a case of a complete staging procedure for Hodgkin's disease including splenectomy, performed laparoscopically. The patient had an uneventful recovery and returned to work 11 days postoperatively. While performing this operation laparoscopically does not alter the indications for the procedure, laparoscopic staging of Hodgkin's disease may result in shorter hospitalization and recovery time while providing complete pathologic staging of subdiaphragmatic disease.

Background The double-stapling technique (DST) is frequently used in laparoscopic sigmoidectomy. Unfortunately, anastomotic leakage after laparoscopic intracorporeal colorectal anastomosis with DST is seen with some frequency. Methods We performed DST on 40 patients (June 2007 to August 2008) and hemi-DST on 50 patients (September 2008 to December 2011) undergoing laparoscopic sigmoidectomy. Results There were no occurrences of anastomotic leakage in the hemi-DST group, and 2 instances of anastomotic leakage in the DST group were observed. In these patients, the leakage appeared at the lateral intersecting anastomotic margins. Conclusions Using the hemi-DST for laparoscopic intracorporeal colorectal anastomosis will make laparoscopic sigmoidectomy a safer procedure.

Injuries to the posterior cruciate ligament (PCL) and methods of treatment of the injured PCL have historically been surrounded by controversy in the orthopedic community. The infrequent occurrence of PCL injuries and PCL-based, multiple ligament knee injuries has led to limitations in clinical studies and a subsequent lag in basic science and clinical research compared with that for other ligamentous injuries. In recent years, new studies have elucidated the biomechanical function and complex anatomy of the PCL leading to an increased interest in research, understanding, and treatment of these complex injuries. In addition to improved understanding of knee ligament structure and biomechanics, technical advancements in allograft tissue, surgical instrumentation, and graft tensioning and fixation methods and improved surgical techniques and postoperative rehabilitation methods have enhanced the results in PCL reconstruction and PCL-based, multiple ligament knee surgical outcomes.

From eliminating the side effects of chemotherapy to treating Alzheimer's disease, the potential medical applications of nanorobots are vast and ambitious. In the past decade, researchers have made many improvements on the different systems required for developing practical nanorobots, such as sensors, energy supply, and data transmission. A few generations from now someone diagnosed with cancer will be offered a new alternative to chemotherapy. The traditional treatment of radiation that kills not just cancer cells but healthy human cells as well, causing hair loss, fatigue, nausea, depression, and a host of other symptoms. A doctor practicing nanomedicine would offer the patient an injection of a special type of nanorobot that would seek out cancer cells and destroy them, dispelling the disease at the source, leaving healthy cells untouched. The extent of the hardship to the patient would essentially be a prick to the arm. A person undergoing a nanorobotic treatment could expect to have no awareness of the molecular devices working inside them, other than rapid betterment of their health. This paper presents a study on different approaches employed towards cancer treatment using nano robots. Further it also provides an insight into the future scope in this field of study.

Objectives The purpose of this study was to assess the safety and efficacy of an electrospun multilayered, self-sealing polycarbonate-urethane graft for early hemodialysis access in patients. Method Seventeen eligible consenting patients had a polycarbonate-urethane graft (AVflo™) implanted and followed up prospectively for 12 months or to the end of secondary patency. Performance measures included graft patency, complications, time to first cannulation, and hemostasis times after needle withdrawal. Results All patients were of Asian origin (mean age 57 years, range 29–78). Diabetes mellitus was the most common cause of renal failure (52.9%). There were no systemic or local reactions to the graft. Five patients (29.4%) died due to medical complications unrelated to the device. There was 1 pseudoaneurysm, 3 infected grafts that subsequently thrombosed, and 1 primary thrombosis associated with thrombophilia. One venous stenosis needed balloon angioplasty. Primary and secondary patency rates at 6 months were 72.7% and 81.8%, and at 12 months, 54.5% and 72.7%, respectively. Postimplantation vascular access needs were met entirely by the graft in every instance and prevented the need for venous catheters. Fifty-six percent were accessed within 8 days, the earliest being 48 hours. Finally, all arterial punctures and 98% of venous punctures had sealed in less than 5 minutes, with two thirds sealing off within 3 minutes of needle withdrawal. Conclusion The electrospun polycarbonate-urethane graft is safe in humans, permits early access obviating the need for venous catheters, and has equivalent patency to other prosthetic grafts at 1 year.

The ForceTriad™ generator has been recently developed. This new electrosurgical generator would demonstrate improved quality and efficiency in blood vessel sealing.To compare currently available 10-mm laparoscopic electrosurgical devices with the LigaSure™ Vessel Sealing System and ForceTriad generator (Valleylab, Inc., a division of Tyco Healthcare) for use in vessel sealing.Blood vessels of various types and diameters were harvested from alive four pigs using three instruments: LigaSure Atlas™ with LigaSure Vessel Sealing Generator (LSAt), LigaSure Atlas with ForceTriad Generator (LSAtFT), and Endoclip™ II (Autosuture, USSC; a division of Tyco Healthcare). A total of 100 arteries were processed by removal of fatty and connective tissue from the adventitia before sealing. An additional set of specimens was sealed and histopathologically analyzed after being stained with hematoxylin and eosin.The mean burst pressure was significantly higher with LSAtFT compared to LSAt (P 0.01). The sealing process was significantly shorter with LSAtFT (P 0.05). With regard to the degree of thermal injury, adventitial collagen denaturation and proximal thermal injury to the smooth muscle in the media of the vessel wall were less common with LSAtFT; however, the numbers were too small for statistical analysis.Both the LSAt and LSAtFT secured all vessel sizes to well above physiologic levels. The LSAtFT could be used more confidently in vessels up to 7 mm. Our findings indicate that LSAtFT could be a safer and more efficient instrument for advanced laparoscopic surgery.

In metastatic spine disease, technologic advancements, neurologic recovery, pain relief, cost-effectiveness, and health-related quality of life have all strengthened surgery's and radiation's role in its management.We evaluated different surgical approaches to the spine and the multimodality treatment in the management of these cases.Recently, the survival rate of malignant spinal metastases has rapidly improved because of early detection and multimodality treatment. The goals of surgical intervention are to prolong survival and improve the quality of life of patients.The recent evolution of imaging, radiosurgery, advanced surgical decompressive techniques and instrumentation, as well as percutaneous vertebral body cement augmentation, needs to be considered in the decision-making to optimize patient outcomes.Management of patients with spine tumors requires a multidisciplinary team that includes a medical and radiation oncologist and a spine surgeon. Newer surgical techniques that address both tumor resection and spinal stabilization offer the best outcome in selected patients. The prognostic parameters suggested for metastatic spine tumors include the general condition of the patient, neurological status number of spinal and extraspinal metastases, primary site of the cancer, visceral metastasis, and severity of spinal cord compression.

Use of biosutures in animal models of colonic anastomoses is associated with decreased adhesions without affecting anastomotic strength. This study aimed to evaluate the effect of biosutures on colonic anastomoses kept free of adhesions by peritoneal instillation of icodextrin 4%.Three types of colonic anastomoses were compared: group 1, anastomoses without icodextrin 4% and control suture; group 2, anastomoses with icodextrin 4% (adhesion-free anastomoses) and control suture; and group 3, anastomoses with icodextrin 4% (adhesion-free anastomoses) and biosutures. Dehiscence, adhesion formation, and anastomotic strength were evaluated on day 4 after the operation.When peritoneal icodextrin 4% was used in anastomoses with conventional sutures, a decrease in the adhesion index (P = 0.01) and a lower bursting pressure (P = 0.15) were observed. When adhesion-free anastomoses were compared, those performed with biosutures had a higher bursting pressure (P = 0.008) and a similar pattern of adhesion index (P = 0.48).Biosutures improve the strength of adhesion-free colonic anastomoses.

Introduction Advanced laparoscopic courses serve as a comprehensive and popular Continuing Medical Education (CME) activity. Knowledge of basic laparoscopy is an assumed prerequisite for attendance at these courses. Objective To determine the baseline laparoscopic knowledge of attendees at an advanced laparoscopic surgical course. Methods A.17-question examination was designed using data from the basic laparoscopic quizzes on the Society of American Gastrointestinal Surgeons (SAGES) website ( http://www.sages.org/education/quiz ). The questions covered 4 realms of basic laparoscopy: access, pneumoperitoneum, camera navigation, and surgical instrumentation. The questionnaire was distributed to all attendees at an advanced laparoscopic course at the 2009 Canadian Surgical Forum organized by the Canadian Association of General Surgeons. Results Forty-three respondents completed the survey. Fifty-three percent (53%) of responders had been in practice for more than 10 years and 65% had over 5 years experience. Fifty-five percent (55%) [24/43] of respondents listed laparoscopic courses as the sole means of laparoscopic training. Sixty-one percent (61%) [28/43] were performing > 50 laparoscopic cases per year. The median score on the knowledge-based questions was 70.6% [12/17]. In terms of overall score, respondents with more than 5 years experience performed similarly to respondents with less than 5 years experience (73% correct answers). Interestingly, in a subgroup analysis, respondents performed well in camera skills and pneumoperitoneum-themed questions (84% correct answers) but performed poorly on questions pertaining to instrumentation or access (52% correct answers). Conclusion Basic laparoscopic knowledge among the attendees of an advanced laparoscopic course is suboptimal. A review of basic principles of laparoscopy particularly pertaining to instrumentation and access should form part of these CME activities.

Objective— To determine the number, size, and configuration of ligaclips most resistant to tensile forces when applied to cellophane bands. Study Design— In vitro mechanical evaluation. Sample Population— Single-layer and triple-layer cellophane bands, 9.0 and 11.5 mm ligaclips. Methods— Triple-layer bands were secured with a different number (2–5), size (9.0 or 11.5 mm) or configuration (linear or alternating placement) of ligaclips and mechanically tested. Force-deformation curves were generated and yield load in Newtons (N) was determined for each variable. A 3-way analysis of variance with post hoc Tukey's tests was used for statistical comparisons. Yield load for single-layer and triple-layer bands secured with 4 alternating 11.5 mm ligaclips was compared using a paired-sample (independent) t-test with P

The use of high-frequency vibrations in surgical instruments, commonly referred to as ultrasonic surgical instrumentation, typically involves a frequency of vibration in the range from 20,000 cycles per second (20 kHz) to 60,000 cycles per second (60 kHz). The metal probe or tip of the surgical instrument moves forward and backward at the aforementioned frequencies to create a desired surgical effect. The choice of frequency and the design of the tip of the metal probe determine the application of the instrument and how the device interacts with the targeted tissue.

Neurofibromatosis is a multifaceted disease that often results in tumors of the central nervous system. As our understanding of the molecular biology of the disease improves along with better neuroradiology imaging, surgical instrumentation, and adjunctive care, the management schemes for these patients are evolving. This article reviews what is known about neurofibromatosis, common management problems with respect to the central nervous system, and an approach to the handling of these issues.

We report on the potential uses and benefits of a new development in incisive technology. The harmonic scalpel uses high-frequency mechanical energy to offer the surgeon controlled and precise incision and haemostasis. Vessels up to 2 mm in diameter may be sealed by coaptation with the blade before division. No special training or precautions are required before using this self-cleaning device. It produces considerably less smoke or smell than either diathermy or laser, which reduces the need for instrument exchanges and smoke evacuation. We think that it will be useful for tongue resections and possibly for neck dissections.

Recently, the laparosonic coagulating shears (LCS) have been used widely in laparoscopic surgery. In the current study, the usefulness of LCS for arterial division and hemostasis was examined in porcine arteries.Porcine arteries of several diameters (1, 3, and 5 mm) were removed and divided using LCS with different blade modes: shear, blunt, and flat. The division time and bursting pressure were registered. Additionally, divided sections stained by the Azan-Mallory method were observed microscopically.The division time was dependent on the blade modes used. With the flat mode, the bursting pressure of 5-mm arteries was significantly higher than the bursting pressure with shear and blunt modes. Histologically, cavitation and mild degeneration of the vessel walls occurred adjacent to the cutting edge.The LCS is a safe and useful device for arterial division and hemostasis for 5-mm arteries if an adequate blade mode is used.

A 32-year-old woman underwent laparoscopic cholecystectomy during which there was severe bleeding from the bed of the gallbladder. As application of metallic clips to control the bleeding was not successful, the operation was converted to an open laparotomy. Cholecystectomy was successfully completed without further complications, and the post-operative course was uneventful and the patient was discharged. Eighteen months later, the patient complained of dyspnea. Plain radiograph and computed tomography of the thorax showed a metallic clip in the branch of the pulmonary artery supplying the posterior basal segment of the inferior lobe of the left lung. There was no connection between the patient’s symptoms and the clip embolism. Nevertheless, clip migration or embolism could cause severe complications. Therefore, metallic clips should not be used to stop bleeding from the gallbladder bed.

Surgical resection is the gold standard for treatment of early-stage lung tumors. Different minimally invasive approaches are currently under investigation: In addition to conventional video-assisted thoracoscopic surgery (VATS), robotic technology with the da Vinci System has emerged over the past 10 years.In this series, 26 patients (12 women and 14 men; median age, 65 years) underwent a robotic lobectomy for early-stage lung tumors (clinical stage IA or IB) or centrally located metastases.The resected lobes included four left upper lobes, six left lower lobes, eight right upper lobes, and eight right lower lobes. Five intraoperative conversions to open thoracotomy were performed due to one major bleeding, two minor bleedings, one variant course of the pulmonary artery, and one extended resection. The postoperative complications included two prolonged air leaks, one colonic perforation, and one atrial fibrillation. The median hospital stay was 11 days (range, 7-53 days). One 30-day mortality (3.8%) occurred due to respiratory failure. The overall median operative time was 228 min (range, 162-375 min). For the first five patients, the posterior approach was used. Thereafter, the authors switched to an anterior approach, thus enabling an easier hilar dissection. Technical modification within this series also included the introduction of a new vessel sealing device.Robotic lobectomy was proved to be feasible and safe in our initial series in a learning curve setting. Changes in patient positioning and approach as well as technical modifications resulted in shorter operative times. A longer follow-up period and randomized controlled trials are necessary to evaluate a potential benefit over open and conventional VATS approaches.

Embedding automation can be a step ahead in histology processing development. Among advantages in replacing time-consuming manual embedding, the possibility of the final specimen orientation by the grossing person is very attractive for surgical pathology. There is not yet a satisfactory technological solution for 2 main problems in the design of a sectionable cassette for biopsy specimens and small specimens: maintaining the orientation of the sample at the end of grossing and substitute fine skill manual alignment of the sample at the surface of the block for microtomy. The technical note presents attempts to solve these problems in the design of sectionable cassette. The latest sectionable cassettes by Sakura Finetek for shave and core biopsy specimens are discussed in detail.

Surgical facilities borrow specialty surgical instrumentation and implants from vendors and other facilities to provide needed inventory to perform scheduled procedures without the burden of purchasing these items. Borrowing has many advantages, including reduced costs and the ability to expand services offered, but borrowed items must be handled and processed in a consistent way to ensure safe patient care. Instruments and implants must be received in time to be properly reprocessed by the borrowing facility. Lack of planning on the part of a hospital or vendor, lack of communication, lack of appropriate policies to guide the processing of items, increasingly complex instrumentation, and increasing workloads are factors that can contribute to lapses in processing requirements and, ultimately, risk to patients and staff members. Improving communication and policies and procedures can improve the quality and safety of loaner instrumentation and implant use.

The advent of improved surgical instrumentation and advances in healthcare have driven the rapidly evolving field of orthopedics. There has been a trend toward minimally invasive surgery in order to improve cosmesis, minimize soft tissue trauma, and allow superior fracture healing by minimally disturbing the biological environment around the fracture. Minimally invasive joint replacement surgery, arthroscopic surgery, and locking screw technology have been some of the newer developments in orthopedics that have significantly altered patient care and potentially the outcomes that can be achieved. In this regard, fractures of the distal radius have also been reexamined to see if minimally invasive surgery would be possible in treating this increasingly common fracture of the upper extremity and one of the leading reasons for visits to the emergency room.

A retrospective clinical study of 64 patients who underwent anterior cervical discectomy and fusion (ACDF) with BAK/C for disc degenerative disorders.To evaluate the long-term outcome of BAK/C in the treatment of cervical disc degenerative disorders.ACDF has been demonstrated to be effective in the treatment of cervical disc degenerative disorders. BAK/C, a kind of thread cage widely used for interbody fusion in the lumbar spine, was used in the cervical spine to avoid the donor site complications of traditional autologous bone graft.Sixty-four patients with cervical disc degenerative disorders underwent ACDF with BAK/C technique in our institution between September 1997 and December 2000. All the patients were followed up for at least 6 years. The changes of segmental stability, bone fusion, cervical lordosis, and intervertebral height on radiographs were evaluated in detail immediately after operation, at 6 and 12 months postoperatively, and yearly thereafter. The clinical outcome of neurologic improvement and pain relief was also investigated.Solid fusion was achieved at 1 year postoperatively in all patients, and the segmental stability was maintained during the whole follow-up. The cervical lordosis and intervertebral height were well restored immediately after operation, and gradually lost during the follow-up. Especially, the anterior height of intervertebral space decreased significantly after 1 year, when compared with the anterior height immediately after operation. BAK/C subsidence was observed in 9 patients, including 5 with 1-level fusion, 1 with 2-separated-level fusion, and 3 with 2-adjacent-level fusion, according to the standard of loss of intervertebral height more than 3 mm. BAK/C fusion was generally effective in the treatment of cervical disc degenerative disorders, according to the evaluation of neurologic improvement and pain relief. However, neck pain tended to reoccur in the patients with cage subsidence, and 2 of them even needed revision surgery because of the recurrence of myelopathy and progressive neck pain.Although BAK/C technique was generally effective and safe in the treatment of cervical disc degenerative disorders, the pitfalls of cage design resulted in the disability of maintenance of cervical lordosis and intervertebral height in the long-term follow-up. Cage subsidence, which tended to develop in the patients with 2-level fusion, was possibly responsible for the recurrence of neck pain.

Surgical guides may interfere with effective use of surgical instrumentation during implant placement in the posterior segments where interocclusal distance may be limited.The purpose of this study was to measure and compare the accuracy of posterior implant placement using 3 precision surgical guides with varying occlusogingival heights, and to evaluate the difference in accuracy of implant placement through precision guides as compared to freehand placement.Three groups of surgical guides were fabricated with occlusogingival heights of 4, 6, and 8 mm, respectively. A jig was fabricated to allow for accurate positioning in bone substitute blocks. Ninety implants were placed in the mandibular first molar site on a manikin. Thirty implants (Astra Tech AB) were placed for each group, with 15 through the guide and 15 freehand. Distances between a reference implant and each placed implant were measured at both implant and abutment levels using a coordinate measuring machine. Apex position and angular discrepancy were calculated using the coordinates of the centers of the implant platform and of the occlusal aspect of the abutment. Data was assessed using 2-way ANOVA (alpha=.05).Two-way ANOVA demonstrated that guide height did not significantly affect the accuracy of the implant position. The distance from the reference point to the point of measurement was significantly smaller for placement through the guide compared to freehand placement at both implant (P.001) and abutment levels (P.001). The angular discrepancy was also significantly smaller for placement through the guide (P.001).Precision surgical guides with 4-mm occlusogingival height allow placement as accurate as precision guides with 8-mm height. Placement through the guide reproduced the target position more accurately than freehand insertion.

Mice lacking or over-expressing a gene of experimental interest have become important tools to understand the regulation of kidney function and water and electrolyte homeostasis. The use of mice in physiological studies is becoming more widespread, but there are still a number of technical limitations that preclude the full utilization of mouse models in renal research. The present chapter focuses upon a set of methods developed in our laboratory to quantify renal function in conscious mice. These measurements are based upon surgical instrumentation of mice with chronic indwelling arterial and venous catheters. This preparation permits direct measurement of arterial blood pressure, direct sampling of arterial and/or venous blood, intravenous or intra-arterial infusion of substances, and quantification of daily sodium balance. The advantage of these techniques is that all of these procedures can be performed in conscious mice freely moving in their home cages. As such, this in vivo preparation provides an assessment of physiological function in mice in their native state.