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Background: There is still a debate about the utility of intraoperative cholangiography (IOC) or laparoscopic ultrasonography (LUS) for detection of occult choledocholithiasis during laparoscopic cholecystectomy (LC). The aim of this study was to assess the value of IOC combined with LUS for detection of occult common bile duct (CBD) stones at LC., Material/methods: From Dec 2002 to Aug 2006, 103 patients with moderate risk of CBD stones underwent IOC and LUS simultaneously during LC. The physician teams for the two different procedures were blinded by each other. The sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were calculated by several contingency tables that cross-tabulated the results of each technique with those of the gold standard., Results: The success rate of IOC and LUS were 91.3% and 100% respectively and the time required for LUS was significantly shorter (P<0.01). The visualization of intrapancreatic part of CBD by IOC (97.3%) was significantly higher than LUS (73.8%). The sensitivities, specificities, accuracies, positive and negative predictive values, positive and negative likelihood rations identifying occult CBD stones were 75.0%, 98.7%, 92.2%, 95.5%, 91.4%, 57.7 and 0.253 by IOC, and 82.1%, 98.7%, 94.2%, 95.8%, 93.7%, 63.2 and 0.181 by IUS respectively. The McNemar test showed no significant difference between two methods. The sensitivity of IOC combined with LUS was 92.9%, which was greater than that of IOC and LUS taken separately., Conclusions: LUS is usually performed in case where IOC has failed or is contraindicated. The combination of both methods maximizes intraoperative detection of occult CBD stones and should at least be recommended as two complementary methods.

In order to reduce mutilation, nipple-areola complex (NAC) conservation can be proposed for the treatment of breast cancer when mastectomy is indicated. To reduce the risk of retro areolar recurrence, a novel radiosurgical treatment combining subcutaneous mastectomy with intraoperative radiotherapy (ELIOT) is proposed. One thousand and one nipple sparing mastectomies (NSM) were performed from March 2002 to November 2007 at the European institute of oncology (EIO), for invasive carcinoma in 82% of the patients and in situ carcinoma in 18%. Clinical complications, aesthetic results, oncological and psychological results were recorded. A comparison was performed between the 800 patients who received ELIOT and the 201 who underwent delayed one-shot radiotherapy on the days following the operation. The median follow up time was 20 months (range 1-69) for a follow up performed in 83% of the patients. The NAC necrosed totally in 35 cases (3.5%) and partially in 55 (5.5%) and was removed in 50 (5%). Twenty infections (2%) were observed and 43 (4.3%) prostheses removed. The median rate of the patients for global cosmetic result on a scale ranging from 0 (worst) to 10 (excellent) was 8. Evaluation by the surgeon in charge of the follow-up gave a similar result. Only 15% of the patients reported a partial sensitivity of the NAC. Of the fourteen (1.4%) local recurrences, ten occurred close to the tumour site, all far from the NAC corresponding to the field of radiation. No recurrences were observed in the NAC. In a group of patients characterized by a very close free margin under the areola, no local recurrence was observed. Overall, 36 cases of metastases and 4 deaths were observed. No significant outcome difference was observed between the 800 patients receiving intraoperative radiotherapy (ELIOT) and the 201 patients receiving delayed irradiation.

Initial experiences are reviewed in an integrated operation theater equipped with an intraoperative high-field (1.5 T) magnetic resonance (MR) imager and neuro-navigation (BrainSUITE), to evaluate the indications and limitations. One hundred consecutive cases were treated, consisting of 38 gliomas, 49 other tumors, 11 cerebrovascular diseases, and 2 functional diseases. The feasibility and usefulness of the integrated theater were evaluated for individual diseases, focusing on whether intraoperative images (including diffusion tensor imaging) affected the surgical strategy. The extent of resection and outcomes in each histological category of brain tumors were examined. Intraoperative high-field MR imaging frequently affected or modified the surgical strategy in the glioma group (27/38 cases, 71.1%), but less in the other tumor group (13/49 cases, 26.5%). The surgical strategy was not modified in cerebrovascular or functional diseases, but the success of procedures and the absence of complications could be confirmed. In glioma surgery, subtotal or greater resection was achieved in 22 of the 31 patients (71%) excluding biopsies, and intraoperative images revealed tumor remnants resulting in the extension of resection in 21 of the 22 patients (95.4%), the highest rate of extension among all types of pathologies. The integrated neuro-navigation improved workflow. The best indication for intraoperative high-field MR imaging and integrated neuro-navigation is brain tumors, especially gliomas, and is supplementary in assuring quality in surgery for cerebrovascular or functional diseases. Immediate quality assurance is provided in several types of neurosurgical procedures.

Background: Intraoperative consultation for neurosurgical specimens can be difficult at times, despite the use of both frozen section and squash preparation. Various factors influence the diagnostic accuracy of these procedures. This study was conducted to evaluate reasons for discordant case results in neurosurgical intraoperative consultations and make a comparative analysis of these two commonly used methods to identify the possible pitfalls, errors, and limitations., Materials and Methods: All the neurosurgical cases received in the Department of Pathology for intraoperative consultation over a period of 3 years were studied retrospectively. The slides of frozen sections and squash preparation were retrieved and the diagnosis was compared with the final diagnosis given on paraffin-embedded sections., Results and Observations: A total of 6% of the cases were found to be discordant; these included angiomatous meningioma, Non-Hodgkins lymphoma, metastatic renal cell carcinoma, cerebellopontine angle fibrous meningioma, and craniopharyngioma. Highly vascular lesions, unavailability of squash preparation in a few cases and technical errors like thick smears, excessively crushed specimen, freezing, and cautery induced and crushing artifacts contributed to misdiagnosis., Conclusion: The discrepant cases need to be reviewed regularly by pathologists to familiarize themselves with the morphological changes and artifacts. The knowledge of possible errors could minimize misinterpretation and help in providing a more conclusive opinion to the operating surgeon.

Objective: To evaluate the applicability of low-field intraoperative magnetic resonance imaging (iMRI) during transsphenoidal surgery of pituitary macroadenomas., Methods: Fifty-five transsphenoidal surgeries were performed for macroadenomas (modified Hardy's Grade II-IV) resections. All of the surgical processes were guided by real-time updated contrast T1-weighted coronal and sagittal images, which were acquired with 0.15 Tesla PoleStar N20 iMRI (Medtronic Navigation, Louisville, CO). The definitive benefits as well as major drawbacks of low-field iMRI in transsphenoidal surgery were assessed with respect to intraoperative imaging, tumor resection control, comparison with early postoperative high-field magnetic resonance imaging, and follow-up outcomes., Results: Intraoperative imaging revealed residual tumor and guided extended tumor resection in 17 of 55 cases. As a result, the percentage of gross total removal of macroadenomas increased from 58.2% to 83.6%. The accuracy of imaging evaluation of low-field iMRI was 81.8%, compared with early postoperative high-field MRI (Correlation coefficient, 0.677; P < 0.001). A significantly lower accuracy was identified with low-field iMRI in 6 cases with cavernous sinus invasion (33.3%) in contrast to the 87.8% found with other sites (Fisher's exact test, P < 0.001)., Conclusion: The PoleStar N20 low-field iMRI navigation system is a promising tool for safe, minimally invasive, endonasal, transsphenoidal pituitary macroadenomas resection. It enables neurosurgeons to control the extent of tumor resection, particularly for suprasellar tumors, ensuring surgical accuracy and safety, and leading to a decreased likelihood of repeat surgeries. However, this technology is still not satisfying in estimating the amount of the parasellar residual tumor invading into cavernous sinus, given the false or uncertain images generated by low-field iMRI in this region, which are difficult to discriminate between tumor remnant and blood within the venous sinus.

The discoveries of neural (NSCs) and brain tumor stem cells (BTSCs) in the adult human brain and in brain tumors, respectively, have led to a new era in neuroscience research. These cells represent novel approaches to studying normal phenomena such as memory and learning, as well as pathological conditions such as Parkinson's disease, stroke, and brain tumors. This new paradigm stresses the importance of understanding how these cells behave in vitro and in vivo. It also stresses the need to use human-derived tissue to study human disease because animal models may not necessarily accurately replicate the processes that occur in humans. An important, but often underused, source of human tissue and, consequently, both NSCs and BTSCs, is the operating room. This study describes in detail both current and newly developed laboratory techniques, which in our experience are used to process and study human NSCs and BTSCs from tissue obtained directly from the operating room.

Objective: To summarize our experience in the frozen section (FS) assessment of the trachelectomy surgical margin., Methods: All surgeries from 1994 to 2007 were performed by one surgeon. The FS examination was consistently carried out by a group of gynecologic pathologists according to the protocol described in details in this article. Cases were retrieved from the pathology files and the slides were reviewed by two pathologists., Results: 132 patients were identified with complete pathology records. They ranged from 17 to 46 years old (median 31). Surgeries were performed for clinical Stages 1A (n=39) and 1B (n=93) tumors (63 adenocarcinoma, 59 squamous cell carcinoma, 7 adenosquamous and 3 others). In 78 cases, no residual tumor was seen in the trachelectomy specimens as it was resected by the preceding LEEP or cone. The margin was reported as negative in 123, suspicious in 3 and positive in 6 cases. It was revised in 16 cases (6 positive, 2 suspicious and 8 negative but <5 mm). Final margin assessment agreed with the FS diagnosis in 130 (98.5%) and showed interpretational overcall in 2 cases (1.5%); only one of which resulted in a revised margin. No false negative intraoperative assessment was found., Conclusions: We describe our FS protocol and summarize our data. This protocol is reliable since none of the patients was under-treated.

Unlabelled: Advanced breast cancer screening techniques and their availability increased the number of non-palpable breast lesions requiring surgery. Consequently reliable and efficient therapeutic management permitting accurate localization and removal of these occult lesions is essential., Aims: In our study we evaluated radioguided occult lesion localization (ROLL) for effectiveness of localization, oncological safety and feasibility of concomitant sentinel node biopsy., Methods: Hundred patients (120 lesions) underwent ROLL and tumour excision with or without sentinel node biopsy after confirmed histopathological findings via intra-tumoral injection of Tc99m-labelled macro-aggregate albumin for ROLL and Tc99m-labelled nanocolloids with periareolar-subdermal injection for simultaneous sentinel node biopsy., Results: Our detection rate for ROLL was 98.3%, respectively, 98.6% for sentinel nodes in cases of concomitant sentinel node biopsy. We had a radical excision rate of 55 out of 69 cases of invasive ductal cancer and 17 out of 26 cases of DCIS to achieve 1mm, respectively, 10 mm tumour-free margins., Conclusions: Intra-tumoral tracer injection of for ROLL and periareolar-subdermal tracer injection for simultaneous sentinel node biopsy seem to be a sensitive technique. According to our results ROLL is a safe, precise and simple technique permitting definitive therapeutic removal of malignant or premalignant breast lesions. The high detection rate of the sentinel node in cases with concomitant sentinel node biopsy shows that the combination of both procedures is possible and safe. In our opinion ROLL is an excellent therapeutic option after histological confirmation of malignancy or premalignant disease.

Aim: This study investigated whether intraoperative assessment of SLN status in patients with clinically node-negative breast cancer was improved using touch imprint immunohistochemistry., Material and Methods: Each SLN was cut into slices 2mm thick and evaluated intraoperatively by touch imprint cytology with Papanicolaou staining until the end of 2005, or by a combination of Papanicolaou staining and immunostaining with an anti-cytokeratin antibody from early 2006., Results: When intraoperative cytology of SLN in 85 patients who were clinically node-negative was evaluated with Papanicolaou staining, 81 patients were diagnosed as negative and four were positive. Intraoperative cytology with Papanicolaou staining had a sensitivity of 30%, specificity of 99%, false-negative rate of 70%, false-positive rate of 1.3%, and accuracy of 90.6%. When intraoperative cytology was done with immunohistochemistry plus Papanicolaou staining for SLN evaluation, 92 patients were diagnosed as negative and 17 patients were positive. Intraoperative cytology with immunohistochemistry had a sensitivity of 79%, specificity of 98%, false-negative rate of 21%, false-positive rate of 2.2%, and accuracy of 94.5%. Compared with intraoperative cytology using Papanicolaou staining alone, the combination of immunohistochemistry and Papanicolaou staining achieved a significant increase in sensitivity and a significant decrease in the false-negative rate., Conclusion: Intraoperative SLN evaluation by imprint cytology with immunohistochemistry achieves a more accurate diagnosis of metastasis than imprint cytology alone. This combined method is considered useful for deciding whether to perform axillary lymph node dissection.

Objectives: To evaluate the accuracy of visual examination of myometrial invasion and the involvement of the cervix in the hysterectomy specimen and to explore the role of tumor grade and size in the accuracy of gross estimation of myometrial invasion., Methods: In 142 patients with apparent early endometrial cancer the uterus was opened after its removal and inspected. The size of the tumor (2 cm), the depth of myometrial invasion (less or greater than 50%) and the involvement of the cervix (as positive or negative) were visually estimated and recorded. All patients underwent surgical staging. The gross findings were compared with the final histological results. Estimations of myometrial invasiveness were analyzed according to the tumor grade and size. Accuracy, specificity, sensitivity, positive and negative predictive values were calculated., Results: The overall accuracy rate for myometrial invasion was 81.7% (116/142). False positive and false negative results noted in 17/101 (17%) and 9/41 (21.9%) of patients. Sensitivity, specificity, positive and negative predictive values were 78%, 83.2%, 65.3% and 90.3% respectively. Gross estimation of invasion was more often successful in patients with smaller (

Background/aims: To identify the pyramidal tract by neuronavigation based on intraoperative diffusion-weighted imaging (iDWI) combined with subcortical stimulation., Methods: Seven patients with brain tumors near the deep white matter underwent resection surgery using neuronavigation based on iDWI to visualize white matter bundles. Subcortical electrical stimulation was performed and electromyography was measured at the extremities when surgical manipulation came near the position corresponding to the depicted bundle. We validated the bundle depicted on iDWI by considering the responses to subcortical stimulation and the distance between the stimulation site and the depicted bundle., Results: Positive motor-evoked potentials were detected in 5 of 7 patients (8 stimulations) and the distance from the stimulation site to the depicted bundle was 0-4.7 mm (mean +/- SD, 1.4 +/- 2.1 mm). Negative (no) responses were obtained in all patients when the distance was more than 5 mm. The neuronavigation system had an average error of 0.79 +/- 0.25 mm and a maximum error of 2.0 mm (n = 16)., Conclusion: Neuronavigation based on iDWI combined with subcortical stimulation allowed surgeons to identify the pyramidal tract and avoid inadvertent injury. Our findings demonstrate that the white matter bundles depicted by iDWI can contain the pyramidal tract.

The purpose of this study was to assess the ability of intraoperative tissue staining with consecutive application of 0.4% indigo carmine and 0.5% Congo red to demonstrate the extent and border of oral carcinoma invasion. Seventeen patients were included in the study. Once the oral tumor was resected, a vertical section of surgical specimen was taken from the central part of the tumor. The extent and border of the invaded carcinoma were assessed on digital microscopic examination with tissue staining. The results of assessments were compared with corresponding results of conventional histopathological analysis with HE staining, which is considered the gold standard. Tissue staining produced a brown-black stain on normal muscle, connective, and salivary tissues but not tumor and epithelial tissues. It clearly demonstrated the extent and border of tumor invasion in 13 of 17 patients (76.5%); however, detection of remnant vital tumor cells in scar tissue after neoadjuvant chemotherapy, and distinction between the tumor and adipose tissue scattered in the muscle tissue was difficult. The results of this study showed that intraoperative tissue staining was a possible method in demonstrating the extent and border of carcinoma deeply invaded in the soft tissue and selecting the site for additional frozen section analysis, although the method needed some refinement.

Advances in the treatment of male infertility now routinely allow men with obstructive azoospermia to have fertility treatment without microsurgical reconstruction. A variety of methods for retrieving sperm from men with obstructive azoospermia have been described. The goals of sperm retrieval are to obtain the best quality sperm possible, to retrieve adequate numbers of sperm for immediate use and for cryopreservation, and to minimize damage to the reproductive tract.

The purpose of this Technical Bulletin is to review the perioperative evaluation of men seeking vasectomy reversal and the microsurgical techniques involved in the procedure.

Background: Intraoperative smear cytology provides a rapid and reliable intraoperative diagnosis and guidance to the neurosurgeon during surgical resection and lesion targeting. It also helps the surgeon to monitor and modify the approach at surgery., Objectives: 1) To assess the utility of intraoperative smear cytology and correlate with the final histopathological diagnosis. 2) To describe the cytomorphological features of common brain tumours in smear preparation., Materials and Methods: The material for this study was obtained from 100 consecutive biopsies of central nervous system neoplasms sent for intraoperative consultation. Smears were prepared from the biopsy samples sent in isotonic saline for immediate processing. The smears were stained by the rapid Haematoxylin and Eosin method. The cytomorphological features were noted and correlated with paraffin section findings., Results: Of the total 100 cases, 86 showed accuracy when compared with histopathological diagnosis. This was comparable with other studies. Of the remaining, two cases were frank errors, 12 cases showed partial correlation, with five cases showed incomplete typing of the cell type and seven, discrepancy in grading of tumours. The error percentage was 14%. Correlation with clinical details and radiological findings were helpful in improving the accuracy rate., Conclusions: Smear technique is a fairly accurate, relatively safe, rapid, simple, easily reproducible and cost effective tool to diagnose brain tumours. Smear cytology is of great value in intraoperative consultation of central nervous system pathology.

Aim: The authors investigated the diagnostic value of intraoperative assessment of myometrial invasion in endometrial cancer patients. Following hysterectomy, the uterus was sectioned and macroscopically examined in order to assess the depth of myoinvasion, which was classified as <50% and >50%. In patients with macroscopic depth of invasion>30% and <50%, a frozen section of this area was carried out. The results of intraoperative evaluation were compared with the results of postoperative pathological examination. The agreement between methods was developed as generalized Kappa type statistic. Sensitivity, specificity, positive and negative predictive values for intraoperative only macro and macro/micro evaluation were calculated., Methods: Seventy eight consecutive patients (median age 64 years, range 43-92; median Body Mass Index [BMI] 30.5, range 21.9-46.7) who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy (THBSO) were included in the study. Following intraoperative macroscopic evaluation, frozen section was carried out in 15 (19%) patients. The median time to obtain the results was 16 min for macroscopic evaluation, and 29 min for the macro/micro assessment., Results: Macroscopic only assessment correctly identified depth of myoinvasion in 91% of patients, while, when the frozen section was carried out, myoinvasion was correctly identified in 95% of patients. For macroscopic only and macro-micro assessment sensitivity and specificity were 76% and 98%, 86% and 98%, respectively., Conclusion: These data suggest that the frozen section may improve, the diagnostic value of macroscopic only intraoperative assessment of myometrial invasion in selected patients.

Background: Inherent to minimally invasive procedures are loss of tactile feedback and loss of three-dimensional assessment. Tasks such as vessel identification and dissection are not trivial for the inexperienced laparoscopic surgeon. Advanced surgical imaging, such as 3-charge-coupled device (3-CCD) image enhancement, can be used to assist with these more challenging tasks and, in addition, offers a method to noninvasively monitor tissue oxygenation during operations., Study Design: In this study, 3-CCD image enhancement is used for identification of vessels in 25 laparoscopic donor and partial nephrectomy patients. The algorithm is then applied to two laparoscopic nephrectomy patients involving multiple renal arteries. We also use the 3-CCD camera to qualitatively monitor renal parenchymal oxygenation during 10 laparoscopic donor nephrectomies (LDNs)., Results: The mean region of interest (ROI) intensity values obtained for the renal artery and vein (68.40 +/- 8.44 and 45.96 +/- 8.65, respectively) are used to calculate a threshold intensity value (59.00) that allows for objective vessel differentiation. In addition, we examined the renal parenchyma during LDNs. Mean ROI intensity values were calculated for the renal parenchyma at two distinct time points: before vessel stapling (nonischemic) and just before extraction from the abdomen (ischemic). The nonischemic mean ROI intensity values are statistically different from the ischemic mean ROI intensity values (p < 0.05), even with short ischemia times., Conclusions: We have developed a technique, 3-CCD image enhancement, for identification of vasculature and monitoring of parenchymal oxygenation. This technique requires no additional laparoscopic operating room equipment and has real-time video capability.

Advances in neuroimaging acquisition, computing and image processing have enabled neurosurgeons to use radiological imaging to guide both preoperative planning and intraoperative guidance. In preoperative planning, imaging may be used to evaluate surgical risks, choose the best method of intervention and select the safest surgical approach. Neuronavigation may be useful in designing the surgical flap and alerting the surgeon of surrounding anatomy. Finally, intraoperative imaging may be used to define brain shift associated with the resection of intracranial lesions, assist in more complete lesion resection, and monitor for certain intraoperative complications. In the following review, we briefly examine the history of neuroradiology for neurosurgery, neuronavigation and intraoperative imaging and trace their advances to current systems in use. We will also highlight new experimental applications of neuroimaging that are currently being refined.

Intraoperative radiation therapy (IORT) has been used for over 30 years in Asia, Europe and America as a supplementary activity in the treatment of cancer patients with promising results. Modern IORT is carried out with electron beams (IOERT) produced by a linear accelerator generally used for external beam irradiation (EBRT) or a specialized mobile electron accelerator. HDR brachytherapy (HDR-IORT) has also been applied on selected locations. Retrospective analysis of clinical experiences in cancer sites such as operable pancreatic tumour, locally advanced/recurrent rectal cancer, head and neck carcinomas, sarcomas and cervical cancer are consistent with local tumour control promotion compared to similar clinical experiences without IORT. New emerging indications such as the treatment of breast cancer are presented. The IORT component of the therapeutical approach allows intensification of the total radiation dose without additional exposure of healthy tissues and improves dose-deposit homogeneity and precision. Results of the application of IORT on selected disease sites are presented with an analysis on future possibilities. To improve the methodology, clinical trials are required with multivariate analysis including patient, tumour and treatment characteristics, prospective evaluation of early and late toxicity, patterns of tumour recurrence and overall patient outcome.

Intraoperative radiotherapy (IORT) is a technique where a high, single-fraction radiation dose is delivered during a surgical procedure to macroscopic tumours or tumour beds with minimal exposure of surroundings tissues which are displaced and shielded during the procedure. In this paper, the rationale for and use of IORT, both with electron beams (IOERT) and high-dose-rate brachytherapy (HDR-IORT) are discussed. For most tumours, the likelihood of obtaining local control (LC) improves when increasing doses can be administered. In many clinical situations, however, the dose that can be delivered safely to the tumour target is limited by the risk of damaging normal tissues. Special consideration is therefore given on this paper to the relationship between dose, LC and possible complications. Criteria for patient's selection and evaluation and information on sequencing and techniques are presented as well as some considerations on the need for a proper programme on quality assurance and periodical reporting of data.

Objective: Management of conducting neuroma-in-continuity in primary surgery for obstetrical brachial plexus palsy (OBPP) is still discussed controversially. We present our experience with intraoperative neurophysiological recordings in the management of lesions in continuity in OBPP., Methods: A series of ten children with lesions in continuity of the upper brachial plexus is presented. Due to recordable compound nerve action potentials (CNAPs) and muscle response to motor stimulation across the neuroma, five children underwent external neurolysis of neuroma only (neurolysis group). Due to lack of recordable CNAPs or muscle response, resection of neuroma and interpositional nerve grafting were performed in another five children (resection and grafting group). Functional recovery after at least 30 months of follow-up was assessed., Results: There was a marked difference in functional recovery between the neurolysis and the resection and grafting group. Especially, recovery of shoulder function was disappointing after external neurolysis of conducting neuroma-in-continuity. At the end of follow-up, results of shoulder and elbow function after resection of neuroma followed by interpositional nerve grafting were better without exception., Conclusion: Intraoperative neurophysiological recordings face certain difficulties when used in small children with OBPP. Due to overoptimistic assessment of prognosis after intraoperative CNAP recordings and motor stimulation, the functional results after neurolysis of conducting neuroma-in-continuity are disappointing. Resection of neuroma-in-continuity, conducting or not, offers the best opportunity for maximal functional recovery of the compromised upper limb in OBPP. The role of intraoperative neurophysiological techniques should be confined to the diagnosis of root avulsions.

Introduction: Despite the introduction of neuronavigational systems, radical tumor removal is still problematic in many neurosurgical procedures. Thus, direct intraoperative imaging for tumor resection control was implemented with an intraoperative magnetic resonance imaging (ioMRI) scanner installed in the operating room. Whereas most procedures with ioMRI were carried out in adults, we summarize 7 years of experience using ioMRI in children for interventional neurosurgical procedures or for tumor resection control., Method: An open magnetic resonance scanner (Magnetom Open 0.2 T) was installed in the neurosurgical operating room. For tumor resection control, ioMRI was performed in 35 procedures. After the ioMRI scans were analyzed with respect to quality, the identification of residual tumor was considered by the attending neuroradiologist and neurosurgeon. If residual tumor tissue was present, a new three-dimensional (3D) dataset was acquired to update the neuronavigation; subsequently, the tumor resection was extended. In all these procedures, the results of the ioMRI were checked by an early postoperative high-field magnetic resonance imaging (MRI) study. In addition, ioMRI was carried out in ten other children to monitor interventional neurosurgical procedures., Results: In all children, ioMRI was adequate both for tumor resection control and monitoring of interventional procedures. Primary radical removal of tumor was reached in 40% as confirmed by ioMRI, but in 60% of the patients, the tumor resection procedure was extended after residual tumor was detected using the new 3D dataset for navigational update. By using ioMRI, radical tumor removal improved up to 83% as confirmed by early postoperative MRI. Procedure-related complications were not seen in our series. For all MR-guided biopsies, histology findings could be confirmed, and aspiration of intracranial cysts or abscesses could be monitored online., Conclusion: IoMRI using the open magnetom is suitable for detecting residual tumor tissue, can compensate for the phenomenon of brain shift using a new intraopertive 3D dataset for extended tumor resection, and is capable of monitoring interventional neurosurgical procedures. By using ioMRI for tumor resection control, the degree of tumor resection could be significantly improved.

It is widely accepted that patients with Parkinson's disease experience immediate but temporary improvement in motor signs after surgical implantation of subthalamic nucleus (STN) deep brain stimulating electrodes before the electrodes are activated, although this has never been formally studied. Based on anecdotal observations that limb mobility improved just after microelectrode recording (MER) during deep brain stimulation (DBS) procedures, we designed a prospective study to measure upper extremity bradykinesia using a quantitative measure of angular velocity. Measurements were made pre- and post-MER and during intraoperative DBS. Analysis of 98 STN DBS procedures performed on 61 patients showed that MER did not create adverse clinical symptoms despite concerns that MER increases morbidity. Quantitative upper extremity bradykinesia improved after MER alone, and further improvement was seen during intraoperative DBS. Electrophysiological data from each case were then compared to the improvement in bradykinesia post-MER alone and a significant correlation was found between the improvement in arm bradykinesia, the number of passes through the STN with somatosensory driving, and also with the number of arm cells with somatosensory driving in the STN, but not with total number of passes, total number of passes through the STN, or total number of cells with somatosensory driving in the STN. This study demonstrates that there is a significant improvement in upper extremity bradykinesia just after MER, before inserting or activating the DBS electrode in patients with Parkinson's disease who undergo STN DBS., (Copyright (c) 2006 Movement Disorder Society.)

Objective: To implement fiber tracking in a common neuronavigation environment for routine clinical use to visualize major white matter tracts intraoperatively., Methods: A single-shot, spin-echo diffusion weighted echo planar imaging sequence with six diffusion directions on a 1.5 T magnetic resonance scanner was used for diffusion tensor imaging. For three-dimensional (3-D) tractography, we applied a knowledge-based multiple volume of interest approach. Tracking was initiated in each voxel of the initial seed volume in retrograde and orthograde directions according to the direction of the major eigenvector by applying a tensor deflection algorithm. Tractography results were displayed as streamlines assigned direction encoding color. After selecting the fiber tract bundle of interest by defining inclusion and exclusion volumes, a 3-D object was generated automatically by wrapping the whole fiber tract bundle. This 3-D object was displayed along with other contours representing tumor outline and further functional data with the microscope heads-up display., Results: In 16 patients (three cavernomas, 13 gliomas), major white matter tracts (pyramidal tract, n = 14; optic radiation, n = 2) were visualized intraoperatively with a standard navigation system. Three patients developed a postoperative paresis, which resolved in two in the postoperative course. Additional planning time for tractography amounted to up to 10 minutes. Comparing the tractography results with a fiber bundle generated on a different platform by applying a distortion-free sequence revealed a good congruency of the defined 3-D outlines in the area of interest., Conclusion: Fiber tract data can be reliably integrated into a standard neuronavigation system, allowing for intraoperative visualization and localization of major white matter tracts such as the pyramidal tract or optic radiation.

Objective: Adult gliomas have indistinct borders. As the ratio of neoplastic cells to normal cells becomes lower, the ability to detect these cells diminishes. We describe a device designed to augment intraoperative identification of both solid tumor and infiltrating tumor margins., Methods: A novel, intraoperative, optical spectroscopic tool, using both white light reflectance and 337-nm excitation fluorescence spectroscopy, is described. Discrimination algorithms have been developed to segregate neoplastic tissues from normal glial and neuronal elements. The spectroscopy device was used to measure 5 to 10 locations during glioma resection. Beneath the tool, a biopsy sample was obtained and the pathological results were reviewed in a blinded fashion. Samples were classified as solid tumor, infiltrating tumor, or normal gray or white matter. Comparisons were made between the optical spectra and the histopathological results of sampled areas in evaluating the sensitivity and specificity of the tool for tissue discrimination., Results: Spectral data were obtained from 24 patients with glioma and from 11 patients with temporal lobe epilepsy. A sensitivity of 80% and a specificity of 89% in discriminating solid tumor from normal tissues were obtained. In addition, infiltrating tumor margins were distinguished from normal tissues with a sensitivity of 94% and a specificity of 93%., Conclusion: We have developed a handheld, optical spectroscopic device that may be used rapidly and in near real time with high sensitivity and reproducibility as an optical tissue discrimination tool in glioma surgery.

Object: The majority of investigations on the utility of and indications for intraoperative magnetic resonance imaging (iMRI) have been in adult patients. We report our initial experience utilizing low-field iMRI in pediatric patients., Methods: We performed 21 procedures on 20 patients aged 2 months to 18 years (mean 8.9 years) utilizing the PoleStar -10 iMRI system. The procedures included 15 craniotomies, 2 shunts, and 1 each of the following surgeries: transsphenoidal, craniotomy/transsphenoidal, cranioplasty, and endoscopic biopsy and fenestration. Treated lesions included low-grade astrocytoma (5), craniopharyngioma (3), cortical dysplasia (3), hydrocephalus (2), and others (8). The number of scans ranged from 2 to 5 with a mean of 3.2. Intraoperative imaging and navigation provided valuable information on the extent of resection and catheter placement. In eight procedures it influenced the surgical strategy. No untoward events attributable to the system occurred., Conclusions: The low-field PoleStar -10 iMRI system can safely assist pediatric neurosurgeons treating a variety of diseases. In addition to neuronavigation it provides information on extent of resection, real-time guided catheter placement, and avoidance of complications.

The paper presents the data of a follow-up of 51 patients in whom a bronchial stump suture was additionally fixed at surgery by applying Tochocomb plates (in 30 patients) or an autoangiograft from the removed lung (in 21 patients) in order to prevent a bronchial fistula. The preliminary findings were positively appraised. The authors recommend that this procedure be used in phthisiosurgery and surgical pulmonology.

We use spatially resolved diffuse remittance spectroscopy (DRS) for the measurement of absorption (mu(a)) and reduced scattering (mu(s)') coefficients of normal and malignant breast tissue in vivo during surgery. Prior to these measurements, the linearity of the measurement technique was evaluated on liquid optical phantoms. In addition, the reproducibility of in-vivo tissue measurements was determined on a healthy volunteer. We present results of the in-vivo measurement of optical properties in the wavelength range from 600 to 1100 nm performed during radical mastectomy. A total of 24 patients were included in the study. Both the absorption and reduced scattering properties show large variations. Significant differences in optical properties between normal (glandular plus lipid rich tissue) and tumor tissues are present in 74% of all patients. However, in some cases the tumor showed lower values than normal tissue, and in other cases this was the other way around. Thus, a general trend in optical properties is not observed. However, the average absorption contrast of all patients as a function of wavelength reveals an optimal contrast peak at 650 nm. We believe that this relates to a difference in vascular saturation between tumor and adjacent normal tissue., (Copyright 2004 Society of Photo-Optical Instrumentation Engineers.)

Objective: This study assessed the role of endoscope-controlled microneurosurgery (ECM) in the treatment of intracranial cerebrospinal fluid (CSF) cysts., Methods: Twelve patients affected by symptomatic arachnoid cysts (11 in the sylvian fissure and 1 in the cerebellopontine angle) underwent ECM, in which the endoscope is used to view the operating field while microsurgical instruments can be passed alongside the endoscope for surgical maneuvers. All the cysts were superficially located and could be reached directly through a burr hole on their surface, so that the endoscope was inserted into the cyst without passing through the brain parenchyma. We used a rigid endoscope, performing a wide fenestration of the cyst in the basal cisterns (cystocisternostomy). The excellent endoscopic vision facilitated the surgical procedure with safe maneuvers through a minimally invasive approach. In 11 patients, we observed the resolution of symptoms. A radiological reduction in the cyst was observed in 7 cases. No mortality or major complications were observed., Conclusions: Endoscope-controlled microsurgery is a valid minimally invasive procedure for treating superficially located intracranial arachnoid cysts.

Objective: Thirty-three patients with true neurogenic thoracic outlet syndrome, or Gilliatt-Sumner hand, underwent surgical treatment at Louisiana State University during a 25-year period. This study retrospectively evaluated the outcome referable to pain and motor function in these patients., Methods: All patients had the typical Gilliatt-Sumner hand, secondary to compression of C8, T1, and/or lower trunk. Nineteen patients underwent an anterior supraclavicular approach, and 15 patients underwent a posterior subscapular approach to the brachial plexus. Nerve action potential recordings showed plexus involvement close to the spine, at the level of the junction of the spinal nerves to the lower trunk., Results: Pain, present in 22 patients, improved in 21. Mild motor deficit improved in 12 of 14 patients. Severe motor deficit improved partially in 14 of 20 patients., Conclusion: The diagnosis of true neurogenic thoracic outlet syndrome provides a clear operative indication. Surgical decompression needs to involve the medial portion of the plexus, and especially the spinal nerves. An anterior supraclavicular approach is preferred in most cases. If there is a large cervical rib or there has been a prior anterior operation, then a posterior subscapular approach is indicated.

Objective: We analysed the usefulness of intraoperative electrical stimulation mapping (ESM) for locating motor pathways in pediatric patients harboring cerebral lesions closely related to motor areas., Methods: We applied ESM in 17 consecutive pediatric patients operated on under general anesthesia. It was possible to locate motor function in 15 patients and in all children 5 years old and younger, as well as in all patients presenting with severe motor deficits, using relatively high current intensities. Intraoperative seizures occurred in 20% of our patients. A macroscopically complete removal of the lesion was carried out in 12 cases out of 17 with no definitive postoperative aggravation. Motor function improved for all patients presenting preoperatively with a severe paresis., Conclusion: In our experience ESM revealed to be an useful tool for allowing us to push the resection of any lesion infringing on eloquent cortex up to the limit of functional areas, even in cases in very young and severely paretic children.

The purpose of the study was to estimate the results of macular hole surgery usingpars plana vitrectomy, ILM peeling with and without dye-trypan blue and endotamponade. We observed that trypan blue increases the precision and safety of surgery and improves the postoperative anatomical and functional results.

Adenosine present in human brain glioma extracellular spaces is a marker of astrocyte purine metabolism. In this study, we evaluated adenosine levels in the extracellular fluid of 21 human gliomas of high-grade malignancy using brain microdialysis techniques coupled to high-performance liquid chromatography. The adenosine concentration (mean+/-SEM) within the control tissue was 2.99+/-0.37 microM and in the tumour tissue 1.56+/-0.46 microM. The reduction was statistically significant. It is concluded that the adenosine concentrations reached in the tumour tissue are sufficient to stimulate all adenosine receptor subtypes, suppress local anti-tumour immune responses and affect glial and endothelial cell proliferation.

The purpose of this study was to describe the technique of laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography in the management of renal cell carcinoma with level 1 renal vein tumor thrombus. With the patient in a modified flank position, a transperitoneal four-port approach was used to laparoscopically resect an 8.5-cm right renal mass with tumor thrombus extending to, but not into, the inferior vena cava. Early arterial control with gentle traction on the right renal vein provided a short proximal renal venous segment devoid of tumor on laparoscopic inspection. Intraoperative laparoscopic ultrasonography allowed confident identification of the proximal extent of the tumor thrombus. After hilar control, complete resection and intact removal of the renal specimen was performed using standard non-hand-assisted laparoscopic techniques. The actual surgical time was 180 minutes. Surgical resection was successfully performed laparoscopically. No postoperative complications or hospital readmission occurred. Pathologic examination confirmed T3b renal cell carcinoma with negative surgical margins. Laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography is feasible in the management of renal cell carcinoma with a large-sized level 1 renal vein thrombus. Additional studies are necessary to evaluate its role in urologic oncologic surgery.

Purpose: To analyze the patterns of failure and the toxicity profile of intraoperative electron beam radiotherapy (IOERT) after resection of soft tissue sarcomas of the extremities (STS)., Patients and Methods: Forty-five patients with extremity STS were treated with IOERT and moderate-dose postoperative radiotherapy (45-50 Gy). Twenty-six patients were treated for primary disease (PD) and 19 patients for an isolated recurrence (ILR). Tumor size was >5 cm (maximum diameter) in 36 patients (80%), and high-grade histology in PD patients was present in 14 patients (54%). In nine patients, IOERT was used alone, due to previous irradiation or patient refusal. Chemotherapy (neoadjuvant and/or adjuvant) was mainly given to high-grade tumors., Results: Nine patients relapsed in the extremity (20%), and 12 patients in distant sites (28%). Actuarial local control at 5 years was 88% for patients with negative/close margins and 57% for patients presenting positive margins (P=0.04). Five patients (11%) developed neuropathy associated with the treatment. Extremity preservation was achieved in 40 patients (88%). With a median follow-up of 93 months (range: 27-143 months) for the patients at risk, 25 patients remain alive (a 7-year actuarial survival rate of 75% for PD and 47% for ILR; P=0.01)., Conclusions: IOERT combined with moderate doses of external beam irradiation yields high local control and extremity preservation rates in resected extremity STS. Peripheral nerves in the IOERT field are dose-limiting structures requiring a dose compromise in the IOERT component to avoid severe neurological damage.

Background: In the laparoscopic surgical treatment of early stage colorectal carcinomas, intraoperative tumor site identification is often difficult. We developed a novel marking method using a magnetic marking clip and a modified magnetometer system., Methods: We applied magnetic marking clips at the tumor site during preoperative colonoscopy and identified the clip site with a magnetic marking clip detector system (MMCDS) of our design. Eleven patients who underwent laparoscopic colectomy were studied., Results: In a basic ex vivo study, magnetic bodies of more than 300 mT magnetic force were easily detected with a 100% detection ratio. In a clinical study, the marking site was detected in all 11 patients. The mean length between the detected site and clip along the longitudinal bowel axis was 14.1 mm (SD 5.6). The mean detection time was 2.4 min (SD 0.2)., Conclusion: MMCDS accurately identifies tumor sites. This method may be useful for tumor site identification during laparoscopic colectomy.

Background: Previous reports of laparoscopic cholecystectomy (LC) in patients with biliary pancreatitis suggested increased operative difficulty, high rates of conversion, and greater morbidity and mortality., Methods: Between 1990 and 1997, LC was performed for biliary pancreatitis in 63 patients (Group I) and for other causes in 829 patients (Group II)., Results: Patients with biliary pancreatitis were significantly older (median age 57 vs 50 years, p = 0.009), with greater co-morbidity (ASA III/IV 24% vs 11%, p = 0.008). The groups were comparable with respect to the frequency of previous abdominal operations, acute inflammation of the gallbladder, and the frequency of bile duct calculi detected by intraoperative cholangiography. Moderate to severe adhesions involving the gallbladder were significantly more frequent in patients with biliary pancreatitis (46% vs 29%, p = 0.004). No significant differences were observed between the two groups with respect to intraoperative (1.5% Group I vs 6.0% Group II, p = 0.109) or postoperative complications (10% vs 8%, p = 0.426), conversion rate (0 vs 2.7%, p = 0.181), or duration of operation (median 92 vs 85 min, p = 0.33)., Conclusion: Despite increased age and co-morbidity and more frequent adhesions, our data showed no evidence that intraoperative or postoperative complications were more frequent in patients with biliary pancreatitis than in other patients undergoing LC.

Background: The clinical value of sonographic guidance during video-assisted thoracoscopic surgery (VATS) was studied in 26 patients with peripheral pulmonary nodules., Methods: Twenty-six patients underwent VATS between June 2000 and March 2001 for primary lung cancer (n = 15), pulmonary metastasis (n = 6), and various benign tumors (n = 5)., Results: Sonographic guidance successfully visualized peripheral pulmonary tumors in 21 of the 26 patients (81%). Among them, rich intratumoral blood flow signal was identified in 8 of the 15 primary lung cancers by using color Doppler sonography. The peak velocity was 26 +/- 12.8 cm/s in primary lung cancer and 9.4 +/- 1.7 cm/s in pulmonary metastasis, respectively (p <0.01)., Conclusion: Sonographic guidance during VATS is helpful for locating lesions and determining the extent of surgical resection. The color Doppler method was also useful for evaluating intratumoral blood flow, which yielded significant information for differentiating primary lung cancer, metastatic tumors, and various benign tumors.

Aim: The present study was conducted to evaluate the effectiveness of early scheduled laparoscopic cholecystectomy (LC) following percutaneous transhepatic gallbladder drainage (PTGBD) for patients with acute cholecystitis., Patients and Methods: 31 patients with acute cholecystitis were treated by early scheduled LC following PTGBD (group 1). These patients were compared with 9 patients treated by early LC without PTGBD (group 2) and with 12 patients treated by delayed LC following conservative therapy (group 3) for the success rate of intraoperative cholangiography, the conversion rate to open cholecystectomy, operative time, and hospital stay. Early scheduled LC following PTGBD was defined as scheduled LC when the patient's condition recovered and it was performed 1-7 days (mean: 4 days) after admission. The patients' age in group 1, 2, and 3 was 66 +/- 13, 65 +/- 10, and 64 +/- 9 years, respectively, without significant difference. Most of the patients had additional diseases., Results: The success rate of intraoperative cholangiography was 97% (30/31) in group 1, 67% (6/9) in group 2, and 67% (8/12) in group 3. The conversion rate to open cholecystectomy was 3% (1/31) in group 1, 33% (3/9) in group 2, and 33% (4/12) in group 3. The operative time for LC was 89 +/- 33 min in group 1, 116 +/- 24 min in group 2, and 135 +/- 30 min in group 3. The mean hospital stay after LC was 9 +/- 4 days in group 1, 9 +/- 3 days in group 2, and 17 +/- 7 days in group 3. In group 1, the success rate of intraoperative cholangiography was higher, the conversion rate to open cholecystectomy was lower, and operative time was shorter than in groups 2 and 3 with significant difference (p <0.05, p <0.05, and p <0.01, respectively)., Conclusion: The findings of this study indicate that early scheduled LC following PTGBD is a safe and effective therapeutic option for patients with acute cholecystitis especially in elderly and complicated patients.

Morbidly obese patients are often denied the benefits of sophisticated diagnostic studies and interventions because of the maximum weight limits of available equipment. Two examples in our hospital include a limit of 227 kg (500 lb) on our CT and angiographic tables. We present a patient who was considered to be high risk for recurrent pulmonary emboli and who could not undergo preoperative vena caval umbrella placement, because his weight exceeded the limit of our angiographic table. Intraoperative placement of the umbrella was accomplished by ultrasound localization of the device. We offer this alternative as an adjuvant in the armamentarium of the bariatric surgeon.

Unlabelled: Surgical neck exploration is usually made in primary hyperparathyroidism (PHPT). Localization of the adenoma or detection of hyperplasia may reduce the operation period and limit the extent of the surgery. In this study the effficacy of preoperative Tc-99m MIBI scintigraphy and intraoperative gamma probe was evaluated., Materials and Methods: Six patients with PHPT had preoperative Tc-99m MIBI parathyroid scintigraphy and intraoperative gamma probe (IGP) was used in surgical neck exploration., Results: Parathyroid adenoma was observed in 2/6 patients on scintigraphy in the right retroclavicular region and the left lobe of the thyroid. Both of them were clearly detected by IGP during the surgery and easily removed by the surgeon in a short time (35 min) with a small incision. Pathologic examination confirmed the parathyroid adenoma. No abnormal MIBI uptake was not observed in scintigraphy in 4/6 patients. Subtotal parathyroidectomy was performed in these patients., Conclusion: Preoperative Tc-99m MIBI scintigraphy and the use of IGP may limit the exploration and also the operation time and reduce surgical complications.

Intraoperative magnetic resonance imaging (iMRI) is a new development in medicine that bridges the specialties of surgery and radiology. Deficiencies in the visualization of anatomical architecture and the perception of tumour boundaries in conventional open surgery have led to the integration of imaging within surgery. The superior soft tissue and multiplanar imaging features of magnetic resonance (MR) make this imaging modality superior to that of alternatives. The unique properties of MR to detect heat change and perfusion, and diffusion characteristics of tissue enhance the usefulness of this medium. Concurrent developments in computer aided image guidance and thermoablative technology, herald the era of minimally invasive tumour ablation. Applications have been developed for areas such as neurosurgery, general surgery, gynaecology and urology.

We describe a fast, PC-based optimization planning system for a planar permanent-seed implant. Sites where this system is applicable include brain, lung, and head and neck. The system described here allows placing ribbons of different strengths and of different lengths along and across the implant plane. The program takes full advantage of the availability of different source strengths in inventory, and attempts to find configurations of ribbons that result in optimal dose uniformity over the prescription plane. Dosimetry is based on the AAPM TG 43 Report [R. Nath et al., Med. Phys. 22, 209-234 (1995)]. Compared with TG 43 parameters, the classical tables underestimate the I-125 source strengths needed by 40%. The use of several source strengths improves the plan. Typical optimization yields dose uniformity of 10%, and computing times are within 2-3 min. No further enhancement is obtained if ribbons are placed in a grid pattern as opposed to the (simpler) arrangement along parallel lines. Nor is it valuable to have variable ribbon lengths. For an I-125 implant the optimization system described here is a practical alternative to the (strictly speaking inapplicable) classical systems. It calculates correctly the total source strengths, and--most notably--generates plans with optimal dose uniformity. The fast computing time is well suited for planning during surgery in the operating room.

A 21-year-old woman presented to the accident and emergency department with a 2-day history of lower abdominal pain. Her lips had the stigma of melanosis. Previously, she had received a diagnosis of Peutz-Jeghers syndrome, although no polyps had been detected in small and large bowel barium studies performed approximately 8 years before. Clinically, the patient had mild deep lower abdominal tenderness, and a mass was palpable in the suprapubic region. Urgent ultrasound showed ileoileal intussusception and small polyps in the lumen of the small bowel. At laparotomy, ileoileal intussusception was confirmed. It was not possible to reduce it because of nonviable small bowel, so 20 cm of the ileum, including the intussusception, was excised. After this, intraoperative enteroscopy was performed, showing further polyps in the small bowel distal and proximal to the intussusception, which were excised locally. Only a few reports in the literature describe ultrasound used to diagnose to condition. Intraoperative enteroscopy has been recommended as the treatment of choice because it allows identification of polyps that previously would have been missed.

Background: The use of intraoperative endoscopy by surgeons can identify pathology and help determine the appropriate procedure to perform. However, residency training in endoscopy is often variable and unstructured. The purpose of this study was to determine the indications for and impact of intraoperative endoscopy performed at the time of general surgical procedures., Methods: The records of all patients who underwent intraoperative endoscopy from January 1998 to December 1999 were reviewed. The indications for endoscopy, endoscopic findings, the impact of these findings on the operation performed, complications, and whether the patient was spared from undergoing a second procedure on a separate date were noted., Results: A total of 107 intraoperative endoscopic procedures were performed in 103 patients. Excluding breast, endocrine, central line, and peritoneal dialysis catheter cases, endoscopy was utilized in 5.1% of all general surgery procedures performed during this time period. In 91 patients (88%), the endoscopic procedure was planned preoperatively; in 13 (12%), intraoperative findings dictated its use. The most common indications for endoscopy were identification of lesions and determination of extent of resection (n = 27); evaluation of rectal bleeding (n = 21); colonic evaluation in patients with perianal infections (n = 13); evaluation of extent of injury in trauma cases (n = 8); evaluation of pain (n = 6); evaluation of intestinal tract hemorrhage (n = 6); performance of procedures such as placement of a biliary stent, placement of a nasojejunal tube, or polypectomy (n = 5); and surveillance of chronic disease (n = 5). In 37 patients (36%), the endoscopic findings affected the operation performed. Sixty-nine patients (67%) were spared an endoscopic procedure at a second date, which would have required additional sedation or anesthesia. There were no complications related to endoscopy., Conclusion: Intraoperative endoscopy is a valuable tool that can be performed safely for multiple indications and is frequently of value in determining the operation to be performed. Surgical residents should be trained in the indications for endoscopic evaluation as well as the competent performance of such procedures.