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Correct placement of the femoral and tibial tunnels is the key to rapidly restoring motion and maintaining stability after reconstruction of the anterior cruciate ligament (ACL). Incorrect tunnel placement causes graft failure, which can lead to recurrent instability, stiffness, and prolonged recovery that cannot be prevented by adjusting other variables such as the graft material and size, rehabilitation program, timing of return to sport, and bracing. Unfortunately, there is currently no universally agreed on definition for proper tunnel placement. The most important finding from the Level-I study by Meuffels et al. is that two surgeons, both highly experienced in ACL surgery, had “considerable and unexpected lack of precision in tibial and femoral tunnel placement,” with 40% of tibial tunnel and 60% of femoral tunnel positions being outliers when they randomized the use of conventional and computer-assisted surgical instrumentation for placing the tunnels. It is both enlightening and disconcerting that highly experienced surgeons have poor precision in drilling the tunnels in the intended target. Even with use of “more sophisticated” computer-assisted technology, imprecision and outliers …

Die Second-look-Laparotomie nach Mesenterialinfarkt wird nicht immer routinemasig durchgefuhrt. Angesichts des fortgeschrittenen Alters und des kardiovaskularen Risikos der Patienten wird oft auf eine zweite Operation verzichtet. Zur Senkung des operativen Risikos haben wir die minimal-invasive Technik der Second-look-Laparoskopie entwickelt. In Allgemeinanasthesie wird die alte Wunde im Nabelbereich gespreizt. Ohne Entfernung der fortlaufenden Fasziennabt werden die Bauchdecken an umschriebener Stelle wiedereroffnet. Ein stumpfer Spezialtrokar wird ins Abdomen eingefuhrt und an der Faszie fixiert. Bei etabliertem Pneumoperitoneum kann der gesamte Darm exploriert werden. Bei 5 Patienten nach Darmresektion wegen Mesenterialinfarkt wurde eine Second-look-Laparoskopie durchgefuhrt. In 4 Fallen konnte der intraabdominale Befund korrekt erhoben werden. Bei einer Patientin mislang die Laparoskopie wegen massiv dilatierter Darmschlingen. Die hier beschriebene Technik der Second-look-Laparoskopie ist sehr vielversprechend und wird von uns weiter evaluiert werden.

Many thoracic surgical procedures previously performed using open thoracotomy techniques can now be accomplished using video-assisted thoracic surgical approaches. This has primarily resulted from improvements in both the video and surgical instrumentation and the development of an effective endoscopic surgical stapling device. Laser technology that has been adapted for use in endoscopic surgery has been extended to video-assisted thoracic surgical applications for the resection of pulmonary nodules difficult to manage with the endoscopic stapler alone. We present our experience with the neodymium:yttrium-aluminum garnet laser as either a primary resective tool or as an adjunct to the endoscopic stapler in 67 consecutive patients who underwent video-assisted thoracic surgical wedge resection of the lung.

"Microneedle" electrocautery was compared against the standard-size needle electrocautery and the Shaw hemostatic scalpel to determine the differences in tissue necrosis when used as a cutting instrument. Incisions were made on the dorsal skin of anesthetized white rats using each of the three devices with the no. 15 scalpel as control. The specimens were submitted for histological evaluation. The microneedle caused less necrosis than the standard-size needle electrocautery (0.18 vs 0.27 mm, p < 0.01) and less necrosis than the Shaw hemostatic scalpel set at 220 degrees F (0.18 vs 0.25 mm, p < 0.05). The microneedle electrocautery was also found to be an instrument that causes very little tissue distortion during fine dissection and helps to minimize blood loss in craniofacial and neurosurgical operations.

Our preliminary experience is presented in the use of the Aachen Computer-Assisted Surgery device for frameless stereotactic puncture and drainage of intracranial abscesses through a 2.1-mm twist-drill hole. The apparatus and technique are described, along with the results of its use in 2 patients. Intraoperatively the semiactive system presents a schematic display of the drainage probe projected into a 3D model of the situs on the monitor screen corresponding to the instrument's position. As the surgeon directs the probe into the abscess the corresponding section is displayed. Thereby drainage is easily achieved under visual control.

Perforation of the esophagus remains a challenge to the thoracic surgeon [1]. Despite modern forms of therapy, the use of hyperalimentation, antibiotics, and better postoperative care, esophageal perforation or rupture continue to be associated with high mortality and morbitity. While the esophagus is infrequently injured as a result of external penetrating trauma in the neck, perforation due to surgical instrumentation, foreign body, or spontaneous rupture were the most common causes in the thoracic esophagus. We review here the data of esophageal perforation in the People’s Republic of China. The purpose of this study is to analyze the causes, surgical treatment, and outcome of esophageal perforation. This paper does not address the issue of postoperative leaks developing in esophageal anastomosis.

Ophthalmology is a field at the forefront of innovation. Improvements in surgical instrumentation and refinements in surgical techniques have resulted in improved outcomes while decreasing operating time. Digital ultrahigh definition microscope utilization, real-time overlays of intraoperative OCT data, and automated laser assisted cataract surgery have been recent major contributions to our field. We believe the next revolution in ophthalmology will be the further development and acceptance of robotics.

The authors described a technique of rapidly reestablishing a pneumoperitoneum after laparoscopically assisted surgery by pulling up and clamping the edge of the wound protector. Our laparoscopic assisted surgical technique for the digestive tract is useful and easy to perform without using special devices.

A new intravascular probe designed to facilitate small vessel, especially coronary artery, anastomosis is presented. Modifications in anastomotic techniques by using the device are discussed.

Minimal access surgery is intended to minimize the trauma of access without compromising exposure of the operative field. Its major benefits include diminished cost of therapy due to a reduced hospital stay and accelerated recovery with early return to full activity. The approaches used in minimal access surgery are laparoscopic, endoluminal, perivisceral, intra-articular, and combined. Many abdominal and thoracic procedures are being adapted to the minimal access approach. Developmental requirements include improvements in light delivery systems; three-dimensional television imaging; better surgical instrumentation; ultrasound probes for internal and external scanning; stapling devices; and tunable, portable solid-state diode lasers. In addition, however, adequate prospective evaluation of laparoscopic procedures, established or new, must be undertaken in the major academic institutions.

Metal stabilizing devices used in beating heart surgery, although largely effective, occasionally slip or cause lacerations of epicardial veins or myocardium, resulting in blood loss that requires time-consuming corrective maneuvers. The use of a fenestrated felt as a cushion in conjunction with the stabilizers eliminates slipping and/or trauma, thus facilitating coronary anastomoses on the beating heart.

Background: Daily clinical observations and a recent study (D Vermeylen et al., 2004) suggest that reflux laryngitis (RL) is involved in apneas/ bradycardias of the newborn. The aim of this study is to develop and tovalidate a unique RL model in newborn lambs to test the assumption that a RL provokesan increase in apneas/ bradycardias/ desaturations observed within thelaryngeal chemoreflexes induced by the contact of a liquid with the larynx. Methods: A surgical instrumentation was performed on the first day of life, which included the insertion of a transcutaneous esophageal catheter in order to allow instillation of a gastric juice surrogate (HCl +pepsin at pH 2) directly on the larynx. The 2 ml-instillations were made 3 times per day for 6 consecutive days. At day 9-10 laryngeal chemoreflexes were induced during sleep. The larynx was removed at the time of necropsy to grade inflammation by a histological study. Results: Lambs in which a RL was induced (n = 4) presented characteristic signs of RL: cough, weak bleat, reduction in weight gain. Preliminary histological analyses showed a characteristic laryngeal inflammation. Preliminary results showing that apneas and oxygen desaturations seem more prominent in RL lambs than controls provided further validation ofour RL model. Conclusion: The ovine model developed in this study presents theclinical and histological characteristics of RL observed in newborns. Preliminary results suggesting that a RL increases apneas/bradycardias/desaturations when a liquid is in contact with laryngealmucosa in the newborn must be confirmed. Supported by: CIHR, FRSQ, Foundation of stars.

Recently, increasing numbers of robotic-assisted laparoscopic radical prostatectomy (RALP) have been performed at many centers. During urethrovesical anastomosis in RALP, surgeons commonly use Large Needle Driver (Intuitive Surgical, Mountain View, Calif). In this study, we report a rare case with intraperitoneal breakage of the jaw of Large Needle Driver.

Despite steady advances in surgical instrumentation and technique, ocular trauma continues to be a leading cause of visual loss in the United States. Almost half of the patients with posterior penetrating injuries are left with severe visual impairment. Controversy persists over the optimal management of the injured eye, including the proper use of prophylactic antibiotics, prophylactic cryopexy, and prophylactic scleral buckling. The role and timing of vitrectomy surgery in severe ocular trauma also remain topics of considerable debate, as does the role of vitrectomy in the management of magnetic intraocular foreign bodies. Each of these issues is discussed, with particular emphasis on conflicting views presented in the relevant literature.

This fact sheet presents a basic guide to making up a surgical instrumentation kit for use either in a laparotomy or abdominal surgery

The availability of telemanipulation robots has not yet resulted in the emergence of a reliable endoscopic coronary bypass procedure. A major challenge in performing a closed-chest coronary operation is creating a high-quality anastomosis in a reasonable period of time. In this experimental study, the impact of distal vessel orientation on the speed and accuracy of anastomosis was quantifed. We found that vessel orientation and the relative angle of the surgical plane influence anastomosis speed, the trauma to the vessel, the accuracy of stitch placement, and the eventual achievement of hemostasis. Our results suggest that the speed and accuracy of a robotically performed anastomosis of a vessel graft to a coronary artery can be improved by making small changes in vessel orientation. Vessels should be positioned between the horizontal and diagonal orientation and inclined between the horizontal and +45. Because the 6-o'clock stitch is particularly challenging, surgeons may benefit from an orientation that moves the heel or the toe of the anastomosis away from this critical position.

From the Departments of Dermatology, University of S~o Panlo, a and the Medical College of Wisconsin. b Reprint requests: Luiz G. M. Castro, MD, Mato Grosso, 128 Higien6polis, 01239-040 S~o Paulo/SP, Brazil. J AM ACAD DERMATOL 1996;34:815-6. Copyright © 1996 by the American Academy of Dermatology, Inc. 0190-9622/96 $5.00 + 0 16/74/69095 ficult. Furthermore, some techniques such as the use of epinephrine, local pressure, or electrocoagulation are often inadequate or dangerous. Because of this, many methods have been used to overcome this problem. One is the use of a single digit tourniquet. Tourniquets exsanguinate the digit before surgery and provide hemostasis. Wide Penrose drains have been used for this purpose. 1 However, they are often cumbersome and too large for small digits. We

New forceps were designed and manufactured which feature a 60° angle and a clay stand for fixing the forceps into the proper position, thus permitting a single surgeon to perform anastomoses more exactly and more quickly.

Saving the physicians time is very desirable in rendering first-rate dermatological service at lower cost. The aim is to reduce surgical instrumentation during skin biopsy procedures and follow-up visits. A combined instrument is used to obtain skin biopsies from 100 patients, and gelatin sponge plugs are used in hemostasis and to assist healing of the biopsy wound site. Skin biopsy samples are obtained simply and with ease, and, as the tissue sample is handled minimally, it appears to be more intact and less distorted in comparison to the usual procedure. Skin biopsy samples can be obtained with the combined instrument in a more cost-effective manner with savings of the physician's time and less instrumentation.

Introduction The enterococci, normal inhabitants of the human and animal bowel flora, were considered for years to be nonvirulent microorganisms. Over the past decade, however, the role of enterococci in human disease has taken on new importance. Serious diseases, such as bacteremia, which is associated with significant mortality, and endocarditis, are prime examples of human enterococcal infections. More recently, the wide-spread use of antimicrobial agents has led to the emergence of multiresistant microorganisms, previously considered to be nonpathogenic, as significant agents in human diseases. Morphologically, enterococci are gram-positive cocci that grow in chains and resemble streptococci. Previously, enterococci were placed in the Lancefield Group D streptococci genus; currently, they are in a new bacterial genus classification Enterococcus (Table). Clinical Diseases Enterococci may cause serious infections in the hospitalized patient and have been reported as the third leading cause of nosocomial infections in the United States. The recovery of enterococci from the urinary tract, surgical wounds, and the blood documents the importance of these bacteria in hospital-acquired infections. [See table in the PDF file] The urinary tract is the most common site infected by enterococci. Surgical instrumentation, intervention, and catheterization are invasive procedures that place the patient at risk for enterococcal infection.

Purpose: Minor hemorrhage during laparoscopic procedures may obscure the operative field. We describe the use of an especially designed, 4 × 4 absorbent sponge for multiple laparoscopic applications.Materials and Methods: The cigarette sponge, also known as the Kittner roll gauze, was routinely used for laparoscopic upper tract procedures. The sponge may be placed easily through ports 5 mm. or greater.Results: The cigarette sponge was excellent for absorbing minor but bothersome bleeding, facilitating suction and blunt dissection, and assisting with retraction.Conclusions: This especially designed laparoscopic sponge dramatically eases laparoscopic procedures, especially for controlling bothersome hemorrhage and blunt dissection. It may decrease operative time and facilitate difficult laparoscopic procedures.

✓ A new encircling clip made of a silicone tube has been designed for treating accidentally injured cerebral vessels. No special holders are necessary. This clip can be tailored depending on the shape of the injured vessel. The clip is a simple and effective tool for achieving complete hemostasis.

A method for low transection of the rectum within a narrow pelvis is described using the new GIA 90 autosuture instrument.

(1997). Intestinal anastomosis with Valtrac biofragmentable ring. Our experience. Journal of Chemotherapy: Vol. 9, No. 2, pp. 146-146.

The microvascular surgical anastomosis remains one of the most technically sensitive aspects of free-tissue transfers. To facilitate these often time-consuming, difficult anastomoses, various anastomotic coupling systems have been introduced. The 3M microvascular anastomotic coupling device, a polyethylene ring-pin device, was found to be highly successful in numerous animal studies. It has been available for use in human subjects for the last 4 years, but clinical experience remains sparse. Our clinical experience with the 3M coupler is reported in 100 free-tissue transfers. The average anastomotic time was 4 minutes. Mean follow-up was 8.6 months, and flap survival was 100 percent. The overall success rate for 3M (MACD) coupler use in microvascular anastomoses is 98.4 percent (121 of 123). Nine abandoned anastomoses were converted to sutured anastomoses intraoperatively. The over-all failure rate for 3M coupler anastomoses is 1.6 percent (2 of 123). We conclude that the 3M device is best suited for minimally discrepant, soft, pliable venous microvascular anastomoses and is unsuitable for end-to-side anastomoses in clinical situations. When carefully and selectively employed by a trained microvascular surgeon, the 3M coupler can be a safe, fast, and reliable adjunct for free-tissue transfers.

This study evaluated the effects of intramedullary instrumentation when used on the femur and tibia. Twenty-six patients (52 knees) undergoing bilateral index cemented total knee arthroplasty were analyzed. Bilateral knee arthroplasties were chosen because the increased surgery would theoretically maximize any perioperative hemodynamic or hematologic changes. Patients were randomized into one of two groups depending on the exact form of surgical instrumentation used. Group I (intramedullary) knees were implanted with standard intramedullary fluted instruments. No special measures to vent the entrance holes were made

• We tested the security of laparoscopic, hemostatic clips in vitro and in vivo. In vitro, the force needed to transversely dislodge clips that were applied to silicone (Silastic) tubing ranged from a mean±SEM of 1.81 ±0.07 N (Endo Clip) to 2.68±0.04 N (Ligaclip). The force needed to axially dislodge clips that were applied to silicone tubing ranged from 4.08±0.20 N (Endo Clip) to 4.78±0.18 N (Ligaclip). In vivo, on mesenteric vessels in anesthetized pigs, 34 of 100 clips that were applied laparoscopically with the Endo Clip were moved or dislodged compared with 11 of 100 of those applied with the Ligaclip. We conclude that laparoscopically placed vascular clips applied with the Ligaclip are more secure than those applied with the Endo Clip. The laparoscopic surgeon should be aware of the relative ease with which clips may be dislodged. ( Arch Surg . 1992;127:718-720)

Ophthalmic Surgical Procedures , by Peter S. Hersh, MD, is an easy-to-read and well-illustrated textbook on the commonly performed ophthalmic surgical procedures. It has a very complete bibliography and index, and it appears to be nicely suited for the medical student rotating through ophthalmology as well as for the ophthalmology resident in training. There are general chapters that discuss surgical instrumentation, sutures, anesthesia, and preoperative and postoperative surgical care, and chapters that review the commonly performed ophthalmic surgical procedures with comments on the indications for the procedure, the preoperative preparation, instrumentation, postoperative care, and potential complications. The reader should realize that the procedures described and illustrated may not be the ones that might be encountered in his or her own particular hospital or training program. The reader of this text should also recognize that what is presented is not the only way that a

Intestinal anastomoses continue to be complicated by leakages even in the best of hands despite the development of new surgical techniques, suture materials, devices, and stapling instruments. One may explain such persistence of anastomotic leakage on the basis of the dynamic effect that multiple factors have on the healing of an anastomosis. Awareness of these factors and proper precautions by the surgeon can make a high-risk anastomosis less prone to leakage. The intracolonic bypass procedure is an alternative to a temporary colostomy. It does not prevent an anastomotic dehiscence but can prevent anastomotic leakage with its associated complications in those situations where dehiscence is most likely to occur.

✓ Cellolite and cottonoid were compared with regard to histological reactions provoked when they were left in contact with the rat brain. Pieces of each material were implanted in 27 rats either extra- or intracerebrally for 48 hours or 28 days. Histological findings suggest that the use of Cellolite for neurosurgery would be unlikely to cause adverse reactions any worse than those caused by cottonoid.

A new instrument system for fast and safe mechanical microvascular anastomosis is presented. It can be used for both end-to-end and end-to-side anastomosis of small arteries and veins and has the potential for use in other small tubular structures. With moderate training, the surgeon can perform the full microvascular anastomosis within 2 to 3 minutes. The device has proved successful in animal studies and in the clinic, with overall patency rates of about 98% in both arteries and veins.

Because dermatologic surgery continues to enjoy widespread popularity as a leading treatment modality for skin disease, the skill and training of the surgeon are critical to patient care. Equally important, however, are the tools the surgeon uses to perform each particular procedure. Surgical instrumentation has often been a confusing subject for the novice surgeon, one in which personal preference often outweighs technical considerations. This article will present the advantages and short-comings of several instruments that constitute the basic armamentarium of the dermatologic surgeon.